Post Acute Case Manager

Sign-On Bonus: $10,000 for qualifying applicants!

This position is responsible for design, deployment and general oversight of selected Skilled Nursing beneficiaries who choose one of our preferred network skilled nursing facilities (SNFs) for post-acute care from the time of identification until the patient is transitioned from skilled Part A coverage. Core responsibilities have a large focus on patient engagement in plan of care, readmission prevention, length of stay management, resource management, and patient experience, keeping care in the system and transition management. This position uses the nursing process to coordinate the delivery of care, including assessment, planning, implementation, and evaluation of outcomes over the transition and adjustment period for patients discharged from the hospital to area SNFs. This position must be able to establish relationships and actively collaborates with members of the healthcare team, including hospital staff, SNF administration, staff, Advanced Practice Providers, and Physicians aimed at improving triple aim outcomes. Works with external skilled facilities to provide on-sight of UnityPoint ACO and Medicare care assigned beneficiaries and vulnerable patients. This position is responsible to design and implement care transition needs including advanced care planning.

Why UnityPoint Health?

• Commitment to our Team - We've been named a Top 150 Place to Work in Healthcare 2022 by Becker's Healthcare for our commitment to our team members.
• Culture - At UnityPoint Health, you Come for a fulfilling career and experience a culture guided by uncompromising values and unwavering belief in doing what's right for the people we serve.
• Benefits - Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you're in.
• Diversity, Equity and Inclusion Commitment - We're committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation.
• Development - We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience.
• Community Involvement - Be an essential part of our core purpose-to improve the health of the people and communities we serve.

Visit us at UnityPoint.org/careers to hear more from our team members about why UnityPoint Health is a great place to work. https://dayinthelife.unitypoint.org/

Accountable for development, presentation, management, quality improvement action plan and oversight of SNF preferred triple aim goals deployment and results and SNF Network

• Leads and coordinates day-to-day SNF network transitions program operations.
• Liaison for work of staff performing SNF transitions work.
• Attends rounds on patients at SNF as able and applicable for Part A episode duration.
• Participates in care planning meetings to assist in comprehensive management of triple aim goals incorporating both the medical and psychosocial needs of the patient in discussions.
• Participates in Medicare A meetings to facilitate and engage SNF staff to ensure all recommended patient care, including attainable patient goals, is continued in the SNF setting.
• Serves as a patient advocate working closely with the team of providers and patient support systems to connect patients with needed services throughout the continuum.
• Works to ensure that patient goals are incorporated into the patients plan of care consistently in the SNF setting.
• Monitors various metrics and milestones to assist in appropriate length of stay and other utilization to ensure timely transitions and stewardship in continuum of care.
• Monitors SNF day use to assist in optimal use of SNF days.
• Collaborates with interdisciplinary team to ensure readmission reviews are completed and measures to mitigate are planned.
• Ensures patient receives education and resource materials related to the self-management of disease state.
• Ensures standardized processes are established in SNFs for patients who are targeted for discharge home post SNF have 7-day follow up visit to re-establish appointment with primary care provider and Home Health Services set up if indicated.
• Leads the SNF network meetings.
• Serves as the point of contact for coordinating quality improvement processes for the care of patients receiving Medicare A services at Skilled Nursing Facility.
• Collects and documents required outcome metrics as needed.
• Reviews and prepares reports to monitor program outcomes as assigned. Shares outcome data with key stakeholders.

Designs and Implements Care Transition Needs

• Implement and facilitates process for post discharge calls to high-risk patients and rising risk as needed.
• Facilitates completion of advanced care planning.
• Recognizes and facilitates consultations and or conversations for Palliative Care and Hospice as appropriate.

Basic UPH Performance Criteria

• Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
• Demonstrates ability to meet business needs of department with regular, reliable attendance.
• Employee maintains current licenses and/or certifications required for the position.
• Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
• Completes all annual education and competency requirements within the calendar year.
• Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g., Medicare and Medicaid) regarding fraud, waste, and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.