RN Care Coordinator - Complex Chronic Care & Transitions

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

Job summary

Provider Partners seeks a Nurse Care Coordinator to drive the PPHP Model of Care (MOC). You will assess, plan, facilitate, coordinate, evaluate, and advocate for services meeting the comprehensive health needs of PPHP members, including those with complex chronic conditions in long-term care.

You will collaborate with nursing staff and a multidisciplinary team to develop integrated care plans, coordinate referrals, and document care plans in the EMR, ensuring quality and cost-effective outcomes.

Qualifications

• Current unrestricted RN license for the state in which the Nurse Care Coordinator is 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 current standard medical practices and experience with Medicare/Medicaid.
• Ability to work with and communicate on a professional level with the interdisciplinary team.
• Excellent independent critical thinking/problem-solving skills.
• Excellent oral and written interpersonal communication, organizational, multi -tasking, and teamwork skills.
• Proficiency in nursing/medical databases and Microsoft programs.
• Positive and enthusiastic attitude.
• 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 re-admissions/avoid inappropriate hospitalizations.
• Conducting and documenting a comprehensive assessment of barriers to care (medical, social, psychosocial, and literacy) promoting a holistic approach to developing the PPHP member’s plan of care.
• Coordinating integrated care plan development, including collaboration with nursing staff, leadership, as well as the entire interdisciplinary team according to the PPHP MOC.
• Facilitation of developing appropriate referrals/consultations.
• Documentation of care plans in the gEHRimed EMR
• Outcomes management and evaluation of the achievement of established goals within the plan of care.
• Ensures initial and annual follow up Model of Care training occurs for employees, providers and contracted personnel associated with ISNP program

Skills

RN license

Critical thinking

Communication

Organizational skills

Interdisciplinary teamwork

Microsoft Office

Nursing databases

Tools

Nursing databases

Job description

Provider Partners seeks a Nurse Care Coordinator to drive the PPHP Model of Care (MOC). You will assess, plan, facilitate, coordinate, evaluate, and advocate for services meeting the comprehensive health needs of PPHP members, including those with complex chronic conditions in long-term care.

You will collaborate with nursing staff and a multidisciplinary team to develop integrated care plans, coordinate referrals, and document care plans in the EMR, ensuring quality and cost-effective outcomes.