RN Care Coordinator -LTC/SNF

Provider Partners Health Plan; Richmond (IN); On-site; USD 65,000 - 85,000; Full time

Job summary

Provider Partners Health Plan is seeking a Nurse Care Coordinator in Indiana to drive Model of Care execution through assessment, planning, facilitation, care coordination, and advocacy for PPHP members with complex care needs. You'll collaborate with the care team to promote quality, cost-effective outcomes and navigate Medicare/Medicaid-related care pathways.

This role emphasizes comprehensive assessments, interdisciplinary collaboration, and efficient documentation within the gEHRimed EMR to

Qualifications

• Current unrestricted RN license for the state of practice.
• Minimum of 3 years clinical care experience.
• Experience in Skilled Nursing Facility / Long Term Care preferred.
• Case management experience preferred.
• Ability to work with interdisciplinary team and communicate professionally.
• Proficiency with nursing/medical databases and Microsoft Office.

Responsibilities

• Case identification/risk stratification to establish needs of PPHP member.
• Collaborate with Transitional Care Team to reduce readmissions and avoid hospitalizations.
• Conduct comprehensive assessments of barriers to care (medical, social, psychosocial, literacy).
• Coordinate care plan development with nursing staff and interdisciplinary team.
• Facilitate referrals and consultations as needed.
• Document care plans in the gEHRimed EMR.
• Manage outcomes and evaluate achievement of care plan goals.
• Ensure Model of Care training for employees and contracted personnel.

Skills

Clinical care

Case management

Interdisciplinary teamwork

Communication

Critical thinking

Nursing databases

Education

RN license

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.