NPST RN Care Coordinator (87727)

Regency Integrated Health Services; Fort Worth (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Cityview Nursing and Rehabilitation Center in Fort Worth, TX seeks an RN Care Coordinator (RNCC) to partner with the Plan NP and coordinate care for ISNP beneficiaries in the nursing facility. The role involves routine member contact with families and staff, and alerting Plan NPs to potential changes in member condition.

The RNCC will participate in rounds, update care plans, and support transitions with hospital systems while ensuring timely follow-up and documentation.

Qualifications

• ADN degree required; RN license in Texas.
• Experience in care coordination within a nursing facility.
• Proficient with documenting in EHR and care plans.

Responsibilities

• Assist the Plan NP with care coordination and documentation; participate in rounds.
• Perform daily rounds and census evaluations; report changes to Plan NPs.
• Collaborate with the ICT to implement care plans and coordinate services.
• Monitor transitions to hospital and communicate status; ensure discharge paperwork is received.
• Follow up in person after transitions to prevent readmission; address patient needs.
• Notify Plan NP of new enrollees and urgent needs; perform other ISNP Plan duties as assigned.

Skills

Care coordination

Assessment

Documentation

Team collaboration

Nursing knowledge

Education

ADN

Tools

EHR systems

Hospital information systems

Job description

Job DetailsJob Location: Cityview Nursing and Rehabilitation Center - Fort Worth, TX 76132Position Type: Full TimeEducation Level: 2 Year DegreeJob Category: Health CarePrimary Responsibilities

The RNCC partners with the Texas Independence Health Plan Institutional Special Needs Plan (ISNP) Nurse Practitioner (Plan NP) to coordinate care for ISNP Beneficiaries (Plan Members), maintaining routine contact with Plan Members, family, and facility staff, and informing Plan NPs and/or facility staff when there are potential medical, emotional, or behavioral changes in a Plan Member’s condition. Functions as a Case/Care Manager and patient healthcare navigator for Texas Independence Health Plan Members within nursing facilities. Weekend on-call support duties, and all other duties as assigned.

Essential Functions

• Assist the Plan NP with care coordination duties and documentation on Plan Members. May initiate, and in some cases, complete assessments with Plan Members collecting vital signs and other administrative care plan data.
• Perform daily rounds to assess changes in Plan Members’ conditions, as well as obtain a daily Plan Member census evaluation, documenting and reporting to Plan NPs and RNPs which Plan Members were transferred out of the Facility (to the Emergency Department or for Hospitalization), who has elected Hospice Care, and who has returned from the Hospital in the past 24 hours.
• Partner with facility staff and other members of the Interdisciplinary Care Team (ICT) to implement care plans for Plan Members and identify and assist in the coordination of specialty or ancillary services, therapy, and/or other referral needs.
• Monitor Plan Members experiencing changes of condition, transitions to and from the hospital or other healthcare environment by working in coordination with facility staff to stay in touch with the hospital for updates and informing the Plan NP of the Plan Member’s hospitalized status. Ensure that the Plan Member’s discharge paperwork and summary are received by the Plan NP.
• Follow-up (in person) timely with each Plan Member after a transition to ensure that the Plan Member is not at risk for a readmission and to inform the Plan NP of any possible medical or other needs the Plan Member may have.
• Alert the Plan NP promptly of new enrollees and place urgency on the Plan NP’s intervention if the Plan Member is at risk for transition at any time.
• Perform all other duties congruent with the ISNP Plan as assigned.

QualificationsEducational/Training Requirements

ADN, current Board Certification

Licensing Requirements

RN

Experience Requirements

The RNCC will comply with all State and Federal guidelines required to practice as a licensed Registered Nurse, including maintaining an active RN license in the state of Texas. The RNCC is responsible for maintaining ongoing Texas Board of Nursing educational requirements for licensure and re-certification.