RN Care Coordinator: Complex Chronic Care

Provider Partners; Marion (IN); On-site; USD 65,000 - 85,000; Full time

Job summary

Provider Partners is seeking a Nurse Care Coordinator to advance the PPHP Model of Care, coordinating assessment, planning, facilitation, care coordination, and advocacy to meet each member's needs. This role emphasizes collaboration with the interdisciplinary team to promote quality and cost-effective outcomes for long-term care residents.

The position requires an active RN license, at least 3 years of clinical care experience, and familiarity with Medicare/Medicaid and EMR documentation.

Qualifications

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

Responsibilities

• Case identification and risk stratification to determine PPHP member needs.
• Collaborate with the Transitional Care Team to reduce readmissions and avoid hospitalizations.
• Assess barriers to care (medical, social, psychosocial, literacy) and develop care plans.
• Coordinate integrated care plan development with nursing staff and leadership.
• Facilitate referrals and consultations as needed.
• Document care plans in the gEHRimed EMR.
• Manage outcomes and evaluate achievement of goals in the plan of care.
• Ensure Model of Care training for employees, providers, and contracted personnel.

Skills

RN license

Case management

Long term care

Interdisciplinary collaboration

Medicare knowledge

Tools

gEHRimed EMR

Microsoft Office

Job description

Provider Partners is seeking a Nurse Care Coordinator to advance the PPHP Model of Care, coordinating assessment, planning, facilitation, care coordination, and advocacy to meet each member's needs. This role emphasizes collaboration with the interdisciplinary team to promote quality and cost-effective outcomes for long-term care residents.

The position requires an active RN license, at least 3 years of clinical care experience, and familiarity with Medicare/Medicaid and EMR documentation.