RN Care Coordinator: Care Continuity & Outcomes

Provider Partners; Rockford (IL); On-site; USD 55,000 - 85,000; Full time

Job summary

Provider Partners is seeking a Nurse Care Coordinator to lead assessment, planning, and care coordination for PPHP members within our Model of Care (MOC). This role emphasizes collaboration with the Transitional Care Team and interdisciplinary staff to promote quality, cost-effective outcomes for long-term care residents.

Ideal candidates hold an active RN license, at least 3 years of clinical experience, and familiarity with Medicare/Medicaid.

Qualifications

• Current unrestricted RN license for the state of practice.
• Minimum 3 years clinical care experience.
• Skilled Nursing Facility/Long Term Care experience preferred.
• Case management experience preferred.
• Medicare/Medicaid knowledge and care coordination experience.
• Ability to communicate with interdisciplinary team.

Responsibilities

• Identify care needs and risk stratify PPHP members.
• Collaborate with Transitional Care Team to reduce readmissions.
• Assess barriers to care across medical, social, and literacy domains.
• Coordinate integrated care plan with nursing staff and interdisciplinary team.
• Facilitate referrals/consultations as needed.
• Document care plans in the gEHRimed EMR.
• Monitor outcomes and evaluate achievement of goals.
• Ensure Model of Care training for staff and contractors.

Skills

Case management

Interdisciplinary collaboration

Critical thinking

Communication skills

Organizational skills

Driving

Teamwork

Education

RN license (state)

Tools

Nursing databases

Microsoft Office

Job description

Provider Partners is seeking a Nurse Care Coordinator to lead assessment, planning, and care coordination for PPHP members within our Model of Care (MOC). This role emphasizes collaboration with the Transitional Care Team and interdisciplinary staff to promote quality, cost-effective outcomes for long-term care residents.

Ideal candidates hold an active RN license, at least 3 years of clinical experience, and familiarity with Medicare/Medicaid.