RN Care Navigator — Chronic Care Coordination in LTC

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

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.