$5,000 Sign-on Bonus for External Candidates

UnityPoint

Family Medicine 2nd Ave - Fort Dodge

M-F 8a-5:00p

As a key member of the interdisciplinary team, contributes important knowledge regarding coordinating team-based care for patients with health concerns by involving the patient, their family, the physicians, and community resources. Also uses nursing skills to assess and educate patients on subjects to include medication, procedures, diet and exercise, and other care requirements.

Care Coordination

• Coordinate and facilitate patient-centered interdisciplinary care and communication, including home health and referring physicians' around interventions leading to the best outcome.
• Provide regular and consistent follow-up during transitions of care with patient, coordinators, and other healthcare professionals in other care settings, including Care Managers and Inpatient Care Coordinators.
• Demonstrates competence in the skills necessary to carry out assigned duties.
• Utilize patient registry tools and predictive analytic tools to guide an action plan for designated patient populations.
• Identify high-risk patients and intervene with the guidance of the provider to improve outcomes.
• Demonstrate clinical leadership as a role model for other staff and provide direction that ensures top of licensure duties for all team members.
• Utilize critical thinking in making independent judgments related to patient care. Maintain responsibility and accountability for the knowledge of conditions of assigned patient populations.
• Engage in process improvement work and quality initiatives to ensure efficient, high quality multidisciplinary care is provided.

Education and Disease Management

• Coach and educate designated patient population and family regarding chronic disease self-management and preventative health maintenance using predefined protocols and evidence-based medicine.
• Work with patients and families to develop and work towards self-management goals through RN only connections.
• Empower patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary utilization.
• Provide consolidated information regarding internal and external resources and services including home health and other community support services to patients/families as well as the healthcare team.
• Support provider in meeting chronic and preventive health care needs by guiding patients in collaborative self-management.

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