RN Care Coordinator: Complex Care & Transitions in LTC

Provider-Partners-Health-Plan-; Richmond (IN); On-site; USD 60,000 - 90,000; Full time

Job summary

Provider Partners Health Plan in Indiana seeks a Nurse Care Coordinator to lead assessment, planning, and care coordination for PPHP members, with a focus on long-term care residents with complex needs.

You will collaborate with the Transitional Care Team, document in the gEHRimed EMR, and ensure follow-up and outcomes evaluation, while supporting providers and staff with Model of Care training.

Qualifications

• Current unrestricted RN license in the practicing state.
• Minimum of 3 years clinical care experience.
• Experience in Skilled Nursing Facility/Long Term Care preferred.
• Case management experience preferred.
• Ability to work with an interdisciplinary team.

Responsibilities

• Identify cases and stratify risk to establish member needs.
• Collaborate with Transitional Care Team to reduce readmissions.
• Assess barriers to care and develop care plans.
• Coordinate integrated care plan with nursing staff and the interdisciplinary team.
• Facilitate referrals/consultations.
• Document care plans in the gEHRimed EMR.
• Manage outcomes and evaluate goals.
• Ensure Model of Care training for staff and providers.

Skills

RN license

Case management

Interdisciplinary collaboration

Critical thinking

Communication

Tools

gEHRimed EMR

Microsoft Office

Job description

Provider Partners Health Plan in Indiana seeks a Nurse Care Coordinator to lead assessment, planning, and care coordination for PPHP members, with a focus on long-term care residents with complex needs.

You will collaborate with the Transitional Care Team, document in the gEHRimed EMR, and ensure follow-up and outcomes evaluation, while supporting providers and staff with Model of Care training.