Registered Nurse Care Coordinator-Eyerly Ball

Overview Create and promote adherence to a person-centered care plan, developed in coordination with client, Eyerly Ball provider, primary care provider, and family/caregiver(s). Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals. Connect clients to relevant community resources, with the goal of enhancing client health and well-being, increasing client satisfaction, and reducing health care costs. Collaborates with all members of the multi-disciplinary healthcare team to ensure the delivery of high quality, cost-effective care, as evidenced by coordinated transitions of care; achievement of select quality outcome metrics; appropriate utilization of health management programs and resources, within the structure of a patient-centered medical home. Success in this position will lead to improved health for the client and reduced health care costs for the managed population of clients. Responsibilities Comprehensive Care Management: Provide outreach activities to members to engage in comprehensive care management. Oversee care management plans that address the needs of the whole person. Care management plan based on information pulled from multiple sources. Organize, authorize and administer joint treatment planning with local providers, members, families and other social support to address the total health needs of members. Provide continuous claims-based monitoring of care to ensure evidence-based guidelines are being addressed with members / families. Serve as active team member, monitoring and intervening on progress of member treatment goals using holistic clinical expertise. Conduct individualized, comprehensive whole person assessments. Care Coordination: Schedule appointments. Make and track referrals and appointments. Monitor follow-up appointments and services. Communicate with providers on interventions/goals. Conduct joint treatment staffing with a multidisciplinary team and client/parent/guardian to plan for treatment and coordination. Support coordination of care with primary care providers and specialists. Identify & ensure individuals have access to primary care services. Ensure ongoing periodic laboratory testing and physical measurement of health status indicators & changes in status of chronic health conditions. Health Promotion: Promote clients’ health and ensure that all personal health goals are included in person-centered care management plans. Promote substance abuse prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and increased physical activity. Provide health education to members and family members about preventing and managing chronic conditions using evidence-based sources. Provide self-management support and development of self-management plans and/or relapse prevention plans so that clients can attain personal health goals. Promote self-direction and skill development in the area of independent administering of medication and medication adherence. Education or training in self-management of chronic diseases. Support and provide assistance in all Eyerly Ball programs as needed and identified. Comprehensive transitional care: Engage clients and/or caretaker as an alternative to the emergency room or hospital care. Participate in the hospital discharge process. Monitor for potential crisis escalation/need for intervention. Complete follow-up phone calls and face to face visits with client/families after discharge from the emergency room or hospital. Individual and Family support services: Advocate for member and family. Assist members to identify and develop social support networks. Assist with medication and treatment management and adherence. Referral to Social and Community Services: Provide resources, referrals or coordination to the following as needed: primary care providers and specialists, wellness programs (including tobacco cessation, fitness, nutrition or weight management programs, and exercise facilities or classes), specialized support groups (i.e. cancer or diabetes support groups, NAMI psychoeducation), school supports, substance use treatment links and treatment, support recovery with links to support groups, recovery coaches, and 12 step program, housing services. Mobile Crisis (Polk Co.) support and collaboration as identified. Qualifications Education: A graduate of an accredited school of nursing. Registered Nurse currently licensed to practice in the State of Iowa. Experience: Knowledge of, and experience in working with adults with mental illness. At least three years of combined experience in both primary health and mental health fields. License(s)/Certification(s): Possess a valid driver’s license, proof of auto liability insurance and a good driving record. Knowledge/Skills/Abilities: Coordination - Adjusting actions in relation to others' actions. Monitoring - Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action. Critical Thinking - Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. Active Listening - Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. Writing - Communicating effectively in writing as appropriate for the needs of the audience. Time Management - Managing one's own time and the time of others. Social Perceptiveness - Being aware of others' reactions and understanding why they react as they do. Customer and Personal Service - Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction. Other: Use of usual and customary equipment used to perform essential functions of the position. #J-18808-Ljbffr UnityPoint Health