RN Care Coordinator -LTC/SNF

Provider Partners; Rockford (IL); On-site; USD 55,000 - 85,000; Full time

Job summary

Provider Partners is seeking a Nurse Care Coordinator to lead assessment, planning, and care coordination for PPHP members within our Model of Care (MOC). This role emphasizes collaboration with the Transitional Care Team and interdisciplinary staff to promote quality, cost-effective outcomes for long-term care residents.

Ideal candidates hold an active RN license, at least 3 years of clinical experience, and familiarity with Medicare/Medicaid.

Qualifications

• Current unrestricted RN license for the state of practice.
• Minimum 3 years clinical care experience.
• Skilled Nursing Facility/Long Term Care experience preferred.
• Case management experience preferred.
• Medicare/Medicaid knowledge and care coordination experience.
• Ability to communicate with interdisciplinary team.

Responsibilities

• Identify care needs and risk stratify PPHP members.
• Collaborate with Transitional Care Team to reduce readmissions.
• Assess barriers to care across medical, social, and literacy domains.
• Coordinate integrated care plan with nursing staff and interdisciplinary team.
• Facilitate referrals/consultations as needed.
• Document care plans in the gEHRimed EMR.
• Monitor outcomes and evaluate achievement of goals.
• Ensure Model of Care training for staff and contractors.

Skills

Case management

Interdisciplinary collaboration

Critical thinking

Communication skills

Organizational skills

Driving

Teamwork

Education

RN license (state)

Tools

Nursing databases

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.