Employment Type:Full timeShift:

Description:The Population Health Acute Care Coordinator responsible to perform key case management functions to ensure continuity of care and services for a defined population. Utilizes the nursing process to transition patients from the acute care setting to the least restrictive next site of care with the goal of preventing crises that lead to readmissions. Ensures continuity of care by collaborating and communicating with physicians, nursing managers, case managers, post-acute case manager and interdisciplinary team members. Is accountable for the coordination of high quality, effective, and appropriate health care transitions. Is accountable for data capture and analysis, outcome achievement and fiscal responsibility by maximizing favorable utilization patterns and minimizing unfavorable expenditures.

Shift: Monday - Friday (8 AM - 4:30 PM)

Essential Position Expectations:

1.    Performs patient identification and risk stratification following the appropriate standard PHSO transition care management care models.
2.    Opens assigned ADT attributed patient notifications in the care management platform; opens acute care protocol accepts patient and documents risk assessment and functional assessment.   
3.    Applies motivational interviewing and teach back during interactions with patient after a transition in care.
4.    Requests documents from outside facilities needed to support care transition discussions.
5.    Confirms PCP and/or specialist follow-up appointments and collaborates with primary care provider team and others to schedule follow-up appointments if they have not been scheduled at time of transition. 
6.    Completes medication reconciliation/medication adherence assessments.
7.    Reviews red flags as appropriate.
8.    Collaborates with care team on strategies to transition patients safely to the next site of care.
9.    Completes resource referrals and performs follow-up to ensure resources met needs.
10.    Extends transition services as needed to prevent/reduce further unnecessary ED or acute care utilization.
11.    Supports quality reporting for population health contracts.
12.    Refers high risk-acuity patients to the RN Ambulatory High Risk Health Coach.
13.    Collaborates with the RN Ambulatory High Risk Health Coach and Provider to answer patient questions and concerns that fall outside of scope.
14.    Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day.
15.    Understands accountability for results and self-manages to support PHSO level success goals in the areas of quality, cost of care and patient experience.
16.    Upholds and supports PHSO standard workflows and procedures at accreditation level quality.

Minimum Qualifications:

Education: Graduate from an accredited school of nursing. BSN preferred.

Experience:  Minimum of 3 years previous nursing experience. Varied clinical experience preferred.

Certifications & Licenses: Iowa state licensure as a Registered Nurse. Basic Life Support required (BLS).

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.