RN Care Coordinator -LTC/SNF

Provider Partners; Plano (TX); On-site; USD 70,000 - 85,000; Full time

Job summary

Provider Partners is looking for a Nurse Care Coordinator based in Plano, Texas. This vital role involves executing the Provider Partners Health Plan Model of Care through collaboration, assessment, care coordination, and advocacy for each member's health needs.

The ideal candidate will possess a valid RN license and have a minimum of 3 years of clinical care experience, emphasizing communication and teamwork skills. Strong nursing expertise in managing complex cases is essential, along with familiarity with Medicare/Medicaid.

Qualifications

• RN license for the state of practice required.
• Minimum of 3 years clinical care experience needed.
• Skilled Nursing Facility/Long Term Care experience preferred.
• Case management experience preferred.
• Ability to communicate professionally with interdisciplinary teams.

Responsibilities

• Identify cases and assess the needs of PPHP members.
• Collaborate with the Transitional Care Team to reduce re-admissions.
• Conduct comprehensive assessments of barriers to care.
• Coordinate integrated care plan development with the interdisciplinary team.
• Facilitate referrals and consultations as needed.

Skills

Nursing expertise in managing complex cases

Excellent communication skills

Critical thinking/problem-solving

Experience with Medicare/Medicaid

Education

Current unrestricted RN license

3 years clinical care experience

Tools

Microsoft programs

Nursing/medical databases

Job description

Overview

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.

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.