Job descriptionArea of Interest : Nursing\nFTE / Hours per pay period : 1.0\nDepartment : Cropp Clinic\nShift : Monday - Friday 8 : 00 am - 4 : 30 pm\nJob ID : 173499\n\nOverview\n\nCreate 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.\n\nCollaborates 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.\n\nWhy UnityPoint Health?\n\nAt UnityPoint Health, you matter. We're proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members.\n\nOur competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you're in. Here are just a few : \nExpect paid time off, parental leave, 401K matching and an employee recognition program.\nDental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members.\nEarly access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family.\n\nWith a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together. \n\nAnd, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience.\n\nFind a fulfilling career and make a difference with UnityPoint Health.\n\nResponsibilities\n\nComprehensive Care Management : \nProvide outreach activities to members to engage in comprehensive care management.\nOversee care management plans that address the needs of the whole person. Care management plan based on information pulled from multiple sources.\nOrganize, authorize and administer joint treatment planning with local providers, members, families and other social support to address the total health needs of members.\nProvide continuous claims-based monitoring of care to ensure evidence- based guidelines are being addressed with members / families\nServe as active team member, monitoring and intervening on progress of member treatment goals using holistic clinical expertise.\nConduct Individualized, comprehensive whole person assessments\n\nCare Coordination : \nSchedule appointments\nMake and track referrals and appointments\nMonitor follow up appointments and services\nCommunicate with providers on interventions / goals\nConduct joint treatment staffing with a multidisciplinary team and client / parent / guardian to plan for treatment and coordination\nSupport coordination of care with primary care providers and specialist.\nIdentify & ensure individuals have access to primary care services.\nEnsure ongoing periodic laboratory testing and physical measurement of health status indicators & changes in status of chronic health conditions.\n\nHealth Promotion : \nPromote clients' health and ensure that all personal health goals are included in person-centered care management plans\nPromote of substance abuse prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and increased physical activity\nProvide health education to members and family members about preventing and managing chronic conditions using evidence-based sources\nProvide self- management support and development of self-management plans and / or relapse prevention plans so that clients can attain personal health goals\nPromote self-direction and skill development in the area of independent administering of medication and medication adherence\nEducation or training in self-management of chronic diseases.\nSupport and provide assistance in all Eyerly Ball programs as needed and identified.\n\nComprehensive transitional care : \nEngage clients and / or caretaker as an alternative to the emergency room or hospital care\nParticipate in the hospital discharge process\nMonitor for potential crisis escalation / need for intervention\nComplete follow-up phone calls and face to face visits with client / families after discharge from the emergency room or hospital\n\nIndividual and Family support services : \nAdvocate for member and family\nAssist members to identify and develop social support networks\nAssist with medication and treatment management and adherence\n\nReferral to Social and Community Services : \nProvide resources, referrals or coordination to the following as needed : \n\nPrimary Care providers and specialist, 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.\nMobile Crisis (Polk Co.) support and collaboration as identified.\n\nQualifications\n\nEducation : A graduate of an accredited school of nursing. Registered Nurse currently licensed to practice in the State of Iowa.\n\nExperience : 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.\n\nLicense(s) / Certification(s) : Possess a valid driver's license, proof of auto liability insurance and a good driving record.\n\nKnowledge / 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.\n\nOther : Use of usual and customary equipment used to perform essential functions of the position.