Cross Continuum Care Manager-RN

Overview

We are hiring a Cross Continuum Care Manager - RN to join our team! The care manager provides care management and population health services to patients within an assigned region. The primary target population to serve is the stratified-risk patient or patients with high vulnerability during transitions between care settings. Care managers create longitudinal, personalized care plans for patients, families, and support systems, collaborate with and coordinate the efforts of the care team across the continuum, and use data analytics to manage the health of populations to improve patient access to care and clinical outcomes.

Hours: Monday-Friday 8am-5pm 

Location: Onsite/hybrid - UnityPoint Clinic Multi-Specialty - Dubuque, IA 

Why UnityPoint Health?

At 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.  

Our 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:      

• Expect paid time off, parental leave, 401K matching and an employee recognition program.   

• Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members.  

• Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family.   

With 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.   

And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience. 

Find a fulfilling career and make a difference with UnityPoint Health.

Responsibilities

Care Management:

Complex Care Management & Longitudinal Planning:

• Provides comprehensive, longitudinal care management for high-risk, high-acuity, and medically complex patients across the continuum. 

• Conducts in-depth, holistic assessments addressing medical complexity, psychosocial needs, health literacy, self-management capacity, and social determinants of health. 

• Develops and maintains individualized, shared care plans in collaboration with interdisciplinary teams to support continuity and progression of care. 

• Coordinates input from multiple providers and settings to manage complexity and reduce fragmentation. 

• Delegates care appropriately while retaining accountability for patient outcomes.

Advance Care Planning (ACP):

• Supports Advance Care Planning by connecting patients and surrogate decision makers to facilitation resources. 

• Ensures ACP documentation is completed, accurately documented, and readily accessible within the electronic health record. 

• Medication & Clinical Coordination 
• Performs medication reconciliation across transitions of care, including inpatient discharge, specialty, and primary care. 
• Collaborates with providers to address medication changes and supports patient understanding of complex medication regimens.

Psychosocial & Resource Coordination:

• Identifies complex behavioral health, social, and environmental barriers impacting care. 

• Coordinates referrals to social work, behavioral health, and community-based resources. 

• Communicates barriers, strengths, and action plans clearly to the interdisciplinary team to support coordinated interventions. 

Care Coordination Across the Continuum:

• Coordinates care across inpatient, outpatient, post-acute, and community settings to support appropriate utilization of services. 

• Facilitates referrals and transitions to specialty care, home health, skilled nursing, palliative care, hospice, and community partners. 

• Monitors patient progress through care transitions and ensures timely follow-up and post-discharge outreach. 

• Leads or participates in interdisciplinary care conferences for patients with prolonged or complex hospitalizations. 

• Utilizes technology platforms and registries to monitor changes in patient condition and intervene proactively.

Education:

• Assesses patient and family readiness, confidence, and knowledge related to chronic disease and complex condition self-management. 

• Provides education using evidence-based materials, action plans, and Teach-Back methodology. 

• Promotes appropriate use of healthcare resources and supports patient engagement through available digital tools.

Population Health, Quality, & Outcomes:

• Manages a defined population of risk-stratified patients with multiple chronic conditions or high risk for hospitalization or readmission. 

• Uses data, registries, dashboards, and alerts to identify care gaps and prioritize interventions. 

• Participates in readmission prevention strategies, root cause analyses, and performance improvement initiatives. 

• Evaluates utilization patterns and outcomes to support quality improvement and value-based care goals.

Qualifications

Education:

• Graduate of an accredited program for Registered Nurses required 
• Bachelor of Science in Nursing (BSN) preferred 

Licenses/Certifications:

• Required: Valid RN license in the state of Iowa. 
• Must obtain IL license after hire. 
• Required: Current BLS certification
• Preferred: Certification in Case Management

Work Experience:

• Three years of clinical nursing experience
• Previous clinical experience in a clinic or home care setting
• Previous experience in care coordination/care management and population health