Essential Functions:
Conduct comprehensive assessments of clients’ holistic health status, including clinical condition, support systems, client/family knowledge, perceptions of the disease process, and community resources.Screen patients for identified and potential needs, making referrals to appropriate multidisciplinary services.Document care management plans, including assessments, client/family participation, consult referrals, and discharge plans.Educate staff, clients, families, and the medical community on care coordination and regulatory issues impacting care and outcomes.Maintain clear and timely documentation in the Electronic Health Record and other systems to ensure effective communication throughout the care continuum.Collaborate with Utilization Management staff regarding payer information, level of care, and patient status determinations.Understand and self-manage to support facility/CIN success goals, including quality improvements, cost of care, and member experience.Identify opportunities for improvement and work with healthcare teams to enhance results at both individual and facility levels.Develop and utilize tools to effectively evaluate, summarize, and communicate patient progress toward outcomes to healthcare team members, patients, and families.Possess knowledge of financial and reimbursement processes, including Medicare DRG payment, case rates, and managed care risk contracting.Coordinate and conduct patient care rounds and family conferences.Collaborate with the Unit Director to achieve unit-based goals related to quality, financial performance, and safety indicators.Demonstrate a strong theoretical and research-based understanding to support sound clinical and psychological practices, including knowledge of pathophysiology and the impact of diseases on functional ability.Serve as a professional role model and mentor to develop and assist others.Perform other duties as assigned by the CIN Director or Care Management/Social Services Manager.Minimum Knowledge, Skills, and Abilities Required:
Current or compact state license as a Registered Nurse issued by the State of Iowa – Required.Three years of acute RN and care coordination experience – Required.Bachelor’s degree in nursing – Preferred.Proof of completion of Mandatory Reporter abuse training specific to the population served within three months of hire.Shift: Full-Time Days
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.