Aspirus Health

Manager

• Assist with anticipating discharge needs of post-surgical patients
• Ensure timely discharge and access to appropriate resources
• Assess medical necessity, level of care, and patient status
• Apply knowledge of community resources, including transportation, skilled nursing facilities, and home health agencies
• Work collaboratively within a team environment
• Work at University Hospital in Madison, Wisconsin

Nurse Case Manager – Coordinated Care

General

• Collaborate with an interdisciplinary team of MDs, APPs, Social Workers, Schedulers, and RN Care Coordination nurses
• Provide care coordination, triage, and case management for patients enrolled in the Home-Based Primary Care program
• Communicate with patients and families via telephone or video communication
• Triage emergent issues
• Provide resources to clients and their families
• Initiate and facilitate consults and referrals
• Update care plans
• Coordinate care with rehabilitation and long-term-care facilities
• Care for homebound adult and geriatric patients

RN – Care Coordination, Home Based Primary Care

Care Coordinator

• Coordinate, align, and sequence program activities and strategic initiatives with Population Health, Ambulatory Care Operations, Ambulatory Social Work, UW Health Legal, UW Office of Legal Affairs, Health Information Management, Information Services, HealthLink Operations, and other internal stakeholders
• Develop workflows and lead optimization of advance care planning implementation and enhancement across UW Health-Wisconsin and the surrounding community
• Promote equity and access to quality care
• Monitor and report existing data to assess organizational advance care planning needs and interventions
• Evaluate and improve program outcomes using evidence-based practice, innovative healthcare delivery systems, patient and provider satisfaction scores, and professional collaboration
• Collaborate with Marketing and Communications to create and deliver advance care planning messaging through social media, digital marketing, media relations, employee communications, and patient communications
• Support community events as needed

Advance Care Planning Program Coordinator

Educator

• Provide education to individuals and groups on a wide variety of topics, with emphasis on diabetes education
• Collect and assess patient health-status data to develop, execute, and evaluate plans of care
• Establish goals and strategies for care-coordination needs across settings with patients, families, and care providers
• Work at 20 South Park Street in Madison, Wisconsin
• Deliver high-quality, compassionate care supporting exceptional patient and family experiences

RN Diabetes Health Educator

Therapist

• Split time between collaborative care and inpatient psychiatry
• Collaborate with medical professionals in a fast-paced environment
• Work with primary care staff and team psychiatrist to deliver brief interventions for adult patients in Primary Care
• Provide short, intense follow-up
• Use outcome-based models to track patient improvement
• Evaluate patients with a wide range of mental health diagnoses
• Collaborate with patients and multidisciplinary teams on individualized treatment plans with specific goals and outcomes
• Collaborate with physicians, occupational therapists, nurses, and psychologists in group therapy program development
• Provide individual and group psychotherapy using multiple evidence-based modalities and methods, focused on crisis stabilization

Behavioral Health Therapist – Primary Care, Inpatient Psychiatry

Customer Support

• Approach donor families and obtain and maintain consent to optimize organ donation
• Provide donor family care through the Donor Family Services Program
• Apply best practices in consent conversations and donor family care
• Participate in and coordinate education for internal and external stakeholders
• Participate in quality improvement and quality assurance and maintain regulatory standards
• Provide support during times of crisis and maintain self-resilience
• Support family follow-up, after-action reviews, and correspondence
• Communicate, coordinate, and collaborate with colleagues and donor service area partners

Nurse Case Manager – Coordinated Care

RN – Care Coordination, Home Based Primary Care

Advance Care Planning Program Coordinator

RN Diabetes Health Educator

Behavioral Health Therapist – Primary Care, Inpatient Psychiatry

Organ and Tissue Donation Support Specialist – Transplant Services