RN Care Navigator: Complex Care & Transitions

Socket.dev; Jasper (IN); On-site; USD 60,000 - 80,000; Full time

Job summary

Socket.dev is seeking a Nurse Care Coordinator to support the PPHP Model of Care (MOC) through assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet members' comprehensive health needs.

The role relies on effective communication and available resources to promote quality, cost‑effective outcomes, including coordination for complex and multiple chronic conditions of long‑term care residents.

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.

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

Critical thinking

Communication skills

Teamwork

Organization

Multi-tasking

Education

Registered Nurse (RN) license

Tools

Nursing databases

Microsoft Office

Job description

Socket.dev is seeking a Nurse Care Coordinator to support the PPHP Model of Care (MOC) through assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet members' comprehensive health needs.

The role relies on effective communication and available resources to promote quality, cost‑effective outcomes, including coordination for complex and multiple chronic conditions of long‑term care residents.