RN Care Coordinator -LTC/SNF

RiseMe; Tell City (IN); On-site; USD 70,000 - 95,000; Full time

Job summary

RiseMe is seeking a Nurse Care Coordinator to lead the assessment, planning, and facilitation of care for PPHP members in a long-term care setting. You will coordinate an interdisciplinary team to develop and monitor individualized care plans and ensure effective referrals and documentation in the gEHRimed EMR.

The role requires a current RN license, at least 3 years of clinical experience, and strong communication skills to optimize quality and cost-effective outcomes within the PPHP framework.

Qualifications

• Current unrestricted RN license in the state of practice.
• Minimum of 3 years of clinical care experience.
• Skilled Nursing Facility/Long Term Care experience preferred.
• Case management experience preferred.
• Ability to work with interdisciplinary team.
• Knowledge of Medicare/Medicaid.
• Strong communication and problem-solving skills.
• Proficiency with nursing/medical databases and Microsoft programs.
• Valid driver’s license and car insurance with reliable transportation.

Responsibilities

• Case identification/risk stratification to establish needs of the PPHP member.
• Collaboration with the Transitional Care Team to reduce readmissions/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

Skills

Clinical care

Case management

Interdisciplinary teamwork

Communication skills

Critical thinking

Organizational skills

Microsoft Office

EMR software

Education

RN license

Tools

EMR software

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.