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Job Description:

Provides clinical coordination services including assessment, planning and intervention. Patients are identified through predictive tools and referrals from providers, staff or community caregivers to facilitate clinical transition planning for medically complex patients from the hospital when medically indicated. May provide initial and concurrent level of care review and insurance authorization activities.

Principle Responsibilities

• Supports the progression of care for complex patients.
  • Completes clinical assessments and participates in patient care rounds to ensure critical interventions and procedures are completed to achieve optimal patient outcomes.
  • Ensures timely progression of care with proactive identification and elimination of potential delays/barriers in patient care. Escalates barriers to leaderships for resolution.
  • Collaborates with healthcare team, community care providers, patients and families to ensure effective clinical and timely transition of care.
  • Provides information and supports activities related to palliative care and advanced care planning to patients and families experience chronic disease progression.
  • Provides age appropriate patient care based on population served.
• Coordinates appropriate clinical transition of patients in the hospital and Emergency Department.
  • Collaborates with interdisciplinary team to plan anticipated transfer or discharge.
  • Serves as subject matter expert with high knowledge base of integrated, seamless post-discharge care and services offered by the system.
  • Assess clinical stability for discharge and oversee clinical details of transitions.
  • Ensures accurate and complete discharge orders.
  • Identifies patients and families with complex discharge issues, rehab services for functional issues to prepare patients for internal or external transitions.
  • Conducts screening or assessment tests to select patients and communicates the need for follow up with community resources in collaboration with provider.
• Participates in care system process that prevent potentially preventable readmissions.
  • Plan and participate in transition conferences with patients and families.
  • Utilize tools and technology to identify and intervene with patients who are at risk for readmission.
  • Ensure that a complete clinical handoff occurs for at risk patient, which may include referrals.
• Collaborates with health care team to promote appropriate length of stay.
  • Utilizes tools and technology to support appropriate length of stay management.
  • Facilitates timely referrals and transfers of information.
  • Ensures outpatient complex clinical care services are in place at the time of discharge along with other complex clinical care needs.
• Demonstrates appropriate clinical resource management and adherence to commercial and regulatory requirements.
  • Supports level of care activities including use of established inpatient guidelines and internal and external utilization criteria.
  • Collaborates with Social Workers to identify trends or concerns related to reimbursement and discharge planning.
  • Ensures timely interventions for patients who are admitted under observation status.
  • Provides information and assistance for identified financial or social needs.
  • Maintains knowledge of government and private payer networks and services.
  • Collaborates with community and health care resources based on need to coordinate care for the patient.
• Other duties as assigned.

Required Qualifications

• Bachelor's degree in nursing
• 2+ years of nursing experience

Licenses/Certifications

• Licensed Registered Nurse - MN Board of Nursing required or
• Licensed Registered Nurse - WI Dept of Safety & Professional Services required
• Case/Care Management Certification within 2 years of hire required, except for Mother/Baby units where an Obstetric/Fetal related certification is acceptable in place of a Case/Care Management Certification or in Cancer Institute where an Oncology Certified Nurse (OCN) certification is preferred upon hire or within 2 years of hire or CKRI the Certified rehabilitation registered nurse (CRRN) is acceptable in place of the case/care management certification
• For positions in the Cancer Institute, must meet at least ONE of the requirements below:
  • Current BLS certification from the American Heart Association
  • Current BLS certification from the American Red Cross
  • Allina in-house BLS training (within 30 days of hire)

Physical Demands

• Light Work:
• Lifting weight up to 20 lbs. occasionally, up to 10 lbs. frequently

Pay Range

Allina Health is committed to adhering with all applicable local, state and federal minimum wage requirements.

Benefit Summary

Allina Health believes the best way to provide safe and compassionate care for our patients is by nurturing the passion of those who care for them. That’s why we devote extraordinary resources to help you grow and thrive — not only as a professional but also as a whole person. When you join our team, you have access to a wealth of valuable employee benefits that support the total well-being — mind, body, spirit and community — of you and your family members.

Allina Health is all in on your well-being. Because well-being means something different to everyone, our award-winning program provides you with the resources you need to help you navigate your personal journey. This includes well-being dollars, dedicated well-being navigators, and many programs, activities, articles, videos, personal coaching and tools to support you on your journey.

We are focused on creating an inclusive workplace so everyone can see themselves as part of our care team. Our care teams are as diverse as the communities we serve and proud to be contributing to the mission of a leading health care organization. Our pioneering approach to well-being helps every member of our care team feel a deep sense of connection and joy in their work.

Benefits include:

• Medical/Dental
• PTO/Time Away
• Retirement Savings Plans
• Life Insurance
• Short-term/Long-term Disability
• Voluntary Benefits (vision, legal, critical illness)
• Tuition Reimbursement or Continuing Medical Education as applicable
• Student Loan Support Benefits to navigate the Federal Public Service Loan Forgiveness Program
• Allina Health is a 501(c)(3) eligible employer

*Benefit eligibility/offerings are determined by FTE and if you are represented by a union.