UnityPoint Health Care Coordinator RN - Pocahontas Clinic in Pocahontas, Iowa

UnityPoint Clinic - Pocahontas

Care Coordinator RN

FTE: .90 (Full-time, 36 hours per week)

Shift: Monday-Friday 8a-5pm with one afternoon off per week

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 Navigators and Patient Care Facilitators.

  • Demonstrates competence in the skills necessary to carry out assigned duties.


  • 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 visits.

  • 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.

Disease Management

  • Support provider in meeting chronic and preventive health care needs by guiding patients in collaborative self-management.

  • Proactively assist providers and other healthcare team members as patient advocate, ensuring progress toward goal attainment.

Population Health

  • Utilize patient registry tools to guide 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.


  • Graduate of an accredited program for Registered Nurses,

  • Current license to practice nursing in the state where care is provided.

  • Mandatory Reporter certification.

  • CPR certification.

  • Achieve and maintain certification in Integrated Care Management within 6 months of hire. The organization will fund one class of Integrated Care Management which includes examination. Additional course work and/or exam fees will be the responsibility of the employee.

  • Meets educational/competency requirements per policy.

Qualifications Preferred:

  • Bachelors of Science in Nursing (BSN)

  • Previous clinical experience in a medical office.

  • Previous process improvement experience.

  • Previous experience in Care Coordination.

Professional Qualities and Attributes:

  • Demonstrate flexibility and adaptability, priority setting, problem solving, conflict resolution, decision-making, work delegation and organization.

  • Must be highly motivated and self-directed.

  • Must be able to communicate effectively with people of diverse professional, educational and lifestyle backgrounds.

  • Ability to understand and apply protocols, policies and procedures.

  • Ability to work independently and assume responsibility for timely completion of assigned functions.

  • Strong computer skills, interpersonal skills, clinical proficiency and ability to work as part of a multi-disciplinary team.

Requisition ID: 2018-50502

Street: 608 NW 7th St

Name: 7020 UnityPoint Health Trinity Regional Medical Ctr

Name: Family Medicine- Pocahontas

FLSA Status: Non-Exempt

Scheduled Hours/Shift: Monday - Friday 8am-5pm with one afternoon off per week.

External Company URL: http://www.unitypoint.org