WEO Nurse Case Manager - Downtown Campus

The University of Iowa Healthcare, Care Coordination Division is seeking a Nurse Clinician/ Nurse Navigator. The role of the Nurse Navigator is to facilitate the progression of care across the continuum for the hospitalized patient through collaboration with the interdisciplinary team which includes but is not limited to patient care staff, providers, patient support, family and community resources. The Nurse Navigator ensures appropriate transitions of care to enable quality outcomes. This position is responsible for ensuring the appropriate utilization of clinical resources with the goal of timely and safe discharges while maintaining healthcare industry compliance. The Nurse Navigator must be adept at driving throughput metrics, clinical effectiveness, and fiscal responsibility.

Duties to Include:

• Perform transition planning activities at the onset and throughout the patient’s hospitalization utilizing clinical skills to create and update personalized transitional care plans at the onset and throughout the patient’s hospitalization.

• Complete the initial assessment or ensures completion of all inpatient/observation patients to identify the barriers that impact the length of stay and discharge planning.  The assessment should also identify the needs of the patients, acknowledge the resources available and anticipate future resource needs for successful transitions.

• Collaborate with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the appropriate level of care for transition planning.

• Assist in discharge planning (referrals) for individuals with continuum of care needs (Post-acute facilities, Home Care, Hospice, etc.). 

• Work collaboratively with Social Work or Care Coordination Team Member to manage social issues that impact the ' transition planning needs, and refer cases of suspected/actual abuse, domestic violence, or neglect  to appropriate agencies".

• Navigate the care delivery system while collaborating with the physician and other clinical departments by ensuring that tests, treatments, consults, and procedures are appropriately indicated and performed timely.

• Articulate the plan of care and communicate this plan to other care team members and patient/caregiver thereby enhancing patient and staff satisfaction.

• Intervene to maintain care progression when a deviation in the plan occurs.

• Lead daily multidisciplinary huddles incorporating evidence/best practice outcomes in the plan and communicate that plan to the health care team, including estimated length of stay, barriers to discharge, and anticipated disposition.  Identify what is needed from the team to facilitate the plan.
• Function as a liaison between the inpatient unit and community-based resources on an as-needed basis.
• Provide assessment, brief counseling, information, referrals, and other resource assistance to patients/families as needed.
• Identify high-risk social situations to intervene in and coordinate resources to promote follow-up care.
• Arrange for community services before discharge to meet patients’ post-discharge needs with recognition and documentation of patient choice of service providers.
• Advocate for the patient/family with other health care professionals and community agencies as indica