RN Care Coordinator -LTC/SNF

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

Job Summary:

The Nurse Care Coordinator will play a key role in the execution of the Provider Partners Health Plan (PPHP) Model of Care (MOC) through the collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet the comprehensive health needs of each member of the PPHP program. Utilizing effective communication skills and available resources, the Nurse Care Coordinator will promote quality, cost-effective outcomes, including care coordination for complex and multiple chronic conditions of the long-term care resident.

Key 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

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.