RN Care Coordinator -LTC/SNF

Socket.dev; Rockford (IL); On-site; USD 65,000 - 88,000; Full time

Job summary

Socket.dev is seeking a Nurse Care Coordinator to lead assessment, planning, facilitation, and advocacy for PPHP Model of Care in the long-term care setting. You will collaborate with the interdisciplinary team to coordinate services and promote quality, cost-effective outcomes.

The role emphasizes comprehensive care management for members with complex chronic conditions, documentation in gEHRimed EMR, and ongoing follow-up training for staff.

Qualifications

• Current unrestricted RN license in the state of practice.
• 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 Medicare/Medicaid.

Responsibilities

• Case identification/risk stratification to establish needs of the PPHP member.
• Collaboration with the Transitional Care Team to reduce readmissions/avoid hospitalizations.
• Conduct comprehensive assessment of barriers to care (medical, social, psychosocial, literacy).
• Coordinate integrated care plan development with nursing staff, leadership and the interdisciplinary team.
• Facilitation of developing referrals/consultations.
• Documentation of care plans in the gEHRimed EMR.
• Outcomes management and evaluation of plan of care goals.
• Ensure initial and annual Model of Care training for staff and contracted personnel.

Skills

RN license

Case management

Coordinated care

Communication skills

Interdisciplinary teamwork

Education

Nursing degree

Tools

EMR systems

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.