RN Care Coordinator -LTC/SNF

Provider-Partners-Health-Plan-; Rockford (IL); On-site; USD 60,000 - 85,000; Full time

Job summary

Provider Partners Health Plan (PPHP) seeks a Nurse Care Coordinator to support the Model of Care by coordinating assessment, planning, facilitation, care coordination, and advocacy for PPHP members with complex chronic conditions in long-term care.

You will collaborate with the Transitional Care Team, document care plans in the gEHRimed EMR, manage outcomes, and ensure follow-up training for staff. An RN license and at least 3 years of clinical experience are required in Illinois.

Qualifications

• Current unrestricted RN license in the state of practice.
• Minimum 3 years of clinical care experience.
• Skilled Nursing Facility/Long Term Care experience preferred.
• Case management experience preferred; knowledge of Medicare/Medicaid.
• Ability to collaborate with an interdisciplinary team; strong communication and problem‑solving.

Responsibilities

• Case identification to establish needs of the PPHP member.
• Collaborate with Transitional Care Team to reduce readmissions.
• Conduct and document comprehensive assessment of barriers to care.
• Coordinate integrated care plan development with nursing, leadership and the interdisciplinary team.
• Facilitate development of referrals/consultations.
• 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 staff and contractors.

Skills

RN license

Clinical care experience

Case management

LTC / SNF experience

Medicare/Medicaid knowledge

Interdisciplinary teamwork

Critical thinking

Communication skills

Documentation in EMR

Microsoft Office

Tools

gEHRimed EMR

Microsoft Word/Excel

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.