RN Care Coordinator: Complex Chronic Care & Transitions

Provider Partners; Jasper (IN); On-site; USD 65,000 - 90,000; Full time

Job summary

Provider Partners is seeking a Nurse Care Coordinator to drive the PPHP Model of Care through assessment, planning, facilitation, and advocacy for residents with complex chronic conditions in long-term care settings.

The role collaborates with the Transitional Care Team, nursing staff, and the interdisciplinary group to develop and monitor individualized care plans, document in the gEHRimed EMR, and ensure ongoing training for staff involved in ISNP programs.

Qualifications

• Current unrestricted RN license for the state practicing.
• 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.
• Ability to work with interdisciplinary team.
• Excellent oral and written interpersonal communication, organizational, multi-tasking, and teamwork skills.
• Proficiency in nursing/medical databases and Microsoft programs.
• Valid driver’s license and car insurance with reliable transportation.

Responsibilities

• Case identification/risk stratification to establish needs of the PPHP member.
• Collaboration with the Transitional Care Team to reduce readmissions/avoid inappropriate hospitalizations.
• Comprehensive assessment of barriers to care (medical, social, psychosocial, and literacy) to develop the plan of care.
• Coordinating integrated care plan development with nursing staff, leadership, and the interdisciplinary team.
• Facilitating referrals/consultations.
• Documentation of care plans in the gEHRimed EMR.
• Outcomes management and evaluation of goals within the plan of care.
• Ensure Model of Care training for employees, providers and contracted personnel.

Skills

Critical thinking

Communication skills

Interdisciplinary teamwork

EMR experience

Nursing databases

Microsoft programs

Positive attitude

Education

RN license (unrestricted)

Tools

gEHRimed EMR

Job description

Provider Partners is seeking a Nurse Care Coordinator to drive the PPHP Model of Care through assessment, planning, facilitation, and advocacy for residents with complex chronic conditions in long-term care settings.

The role collaborates with the Transitional Care Team, nursing staff, and the interdisciplinary group to develop and monitor individualized care plans, document in the gEHRimed EMR, and ensure ongoing training for staff involved in ISNP programs.