RN Care Coordinator -LTC/SNF

Provider Partners Health Plan; Plano (TX); On-site; USD 60,000 - 80,000; Full time

Job summary

Provider Partners Health Plan is searching for a Nurse Care Coordinator in Plano, Texas. This position plays a crucial role in delivering comprehensive care through assessment, planning, and coordination of services for PPHP members. Responsibilities include risk stratification, collaboration with teams to reduce re-admissions, and documentation of care plans.

The ideal candidate will hold an unrestricted RN license, have a minimum of 3 years of clinical care experience, and possess strong skills in nursing, case management, and communication. Supportive team environment with focus on quality outcomes.

Qualifications

• Current RN license in Texas.
• Minimum of 3 years clinical care experience.
• Skilled Nursing Facility/Long Term Care experience preferred.
• Ability to work independently with complex cases.

Responsibilities

• Identify cases and stratify risks for PPHP members.
• Collaborate with Transitional Care Team to reduce re-admissions.
• Conduct comprehensive assessments of barriers to care.
• Develop integrated care plans with interdisciplinary teams.

Skills

Clinical care experience

Case management

Strong nursing expertise

Interpersonal communication

Problem-solving skills

Multi-tasking

Positive attitude

Education

Current unrestricted RN license

Tools

Microsoft Office

nursing/medical databases

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.