RN Care Coordinator: Complex Care & Outcomes

Socket.dev; Rockford (IL); On-site; USD 65,000 - 88,000; Full time

Job summary

Socket.dev is seeking a Nurse Care Coordinator to lead assessment, planning, facilitation, and advocacy for PPHP Model of Care in the long-term care setting. You will collaborate with the interdisciplinary team to coordinate services and promote quality, cost-effective outcomes.

The role emphasizes comprehensive care management for members with complex chronic conditions, documentation in gEHRimed EMR, and ongoing follow-up training for staff.

Qualifications

• Current unrestricted RN license in the state of practice.
• Minimum of 3 years clinical care experience.
• Skilled Nursing Facility/Long Term Care experience preferred.
• Case management experience preferred.
• Strong nursing expertise in managing complex cases with minimal supervision.
• Knowledge of Medicare/Medicaid.

Responsibilities

• Case identification/risk stratification to establish needs of the PPHP member.
• Collaboration with the Transitional Care Team to reduce readmissions/avoid hospitalizations.
• Conduct comprehensive assessment of barriers to care (medical, social, psychosocial, literacy).
• Coordinate integrated care plan development with nursing staff, leadership and the interdisciplinary team.
• Facilitation of developing referrals/consultations.
• Documentation of care plans in the gEHRimed EMR.
• Outcomes management and evaluation of plan of care goals.
• Ensure initial and annual Model of Care training for staff and contracted personnel.

Skills

RN license

Case management

Coordinated care

Communication skills

Interdisciplinary teamwork

Education

Nursing degree

Tools

EMR systems

Microsoft Office

Job description

Socket.dev is seeking a Nurse Care Coordinator to lead assessment, planning, facilitation, and advocacy for PPHP Model of Care in the long-term care setting. You will collaborate with the interdisciplinary team to coordinate services and promote quality, cost-effective outcomes.

The role emphasizes comprehensive care management for members with complex chronic conditions, documentation in gEHRimed EMR, and ongoing follow-up training for staff.