Acute Care Transition Specialist

Overview
MercyOne Central Iowa operates four not-for-profit Catholic medical centers in Des Moines West Des Moines Newton and Centerville and two specialty hospitals - MercyOne Children's Hospital in Des Moines and MercyOne Rehabilitation Hospital in Clive (965 beds total) - along with more than 20 additional facilities that house more than 50 primary care pediatric internal medicine and specialty clinics. Founded by the Sisters of Mercy in 1893 MercyOne Central Iowa has the longest continually operating hospital in Des Moines and is also one of the largest employers in the state with more than 7000 employees and a medical staff of more than 1000 physicians and allied health associates. MercyOne Central Iowa is a member of MercyOne which was founded in 1998 through a collaboration between CommonSpirit Health and Trinity Health - two of the country's foremost not-for-profit Catholic health organizations. MercyOne has more than 20000 colleagues in Iowa and surrounding states.
Responsibilities
Job Summary:
The PHSO Acute Care Management Specialist works as an integral part of an interdisciplinary team to proactively identify patients to ensure continuity of care and services for a defined population. The PHSO Acute Care Management Specialist supports population health patients by closing gaps in recommended clinical care, performing chart reviews, and brings forward patients that my need further follow-up in the Acute Care setting to the least restrictive next site of care.
Essential Position Expectations:

• Utilizes standardized tools and procedures to manage a caseload of patients within the Acute Care or hospital setting.
• Opens assigned ADT attributed patient notifications in the care management platform.
• Reviews EHR documentation to identify patients considered high risk for readmission
• Completes clear and consistent documentation from EHR review within the care management software platform.
• Coordinates with the Acute Care management team for completion of the functional assessment.
• Proactively identifies patients potentially going to a post-Acute Care setting and alerts the Transitional Care Team.
• Transitions patients through data shop to the next level of care (including clinic health coaches, post-Acute Care program manager and inpatient transitions coach) to assure continued coordination post-Acute Care stay.
• Identifies and refers high risk patients to the PHSO ambulatory care management team for care coordination services if appropriate.
• Practices motivational interviewing to support health behavior change.
• Accepts referrals from care management team members to assist with the above position expectations.
• Answers patient questions regarding appointments and/or testing. Addresses potential barriers to care and collaborates with Provider to answer patient questions and concerns that fall outside of scope.
• Documents all patient interactions in the patient's health record or care management documentation system immediately after the call, meeting, or review is completed. The maximum allowable time from interaction to documentation is one business day.
• Supports and participates in PHSO quality improvement activities at the direction of the PHSO Acute and Post-Acute Manager.

Knowledge & Skills:

• Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information.
• Strong communication (verbal/written) and organizational skills and ability to interact effectively with providers, clinic staff, and care management team members across the care continuum.
• Demonstrated capacity to problem solve and prioritize in complex situations.
• Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure.
• Ability to function effectively in a team based environment.
• Obtain Certificate of Competency in Population Health Care Management within 12 months of hire.
• Proof of completion of Mandatory Reporter within three months of hire.

Qualifications
Education: Associates degree preferred.
Experience: Minimum of 3 years health care experience. Varied clinical experience preferred.
Certifications & Licenses: Iowa state licensure as a Licensed Practical Nurse (LPN) or Certified Medical Assistant (CMA). Basic Life Support (BLS) required.