RN Care Navigator for Complex Long-Term Care

Provider Partners; Tell City (IN); On-site; USD 65,000 - 85,000; Full time

Job summary

Provider Partners is seeking a Nurse Care Coordinator to support the PPHP Model of Care by assessing, planning, facilitating, coordinating, and advocating for services to meet the health needs of long-term care members with complex, chronic conditions.

You will partner with the Transitional Care Team and the interdisciplinary staff to identify needs, develop and document care plans, coordinate referrals, and promote high-quality, cost-effective outcomes.

Qualifications

• Current unrestricted RN license for the state in which the Nurse Care Coordinator is practicing.
• Minimum of 3 years clinical care experience.
• Case management experience preferred.
• Knowledge of Medicare/Medicaid.
• Excellent oral and written interpersonal communication, organizational, multi-tasking, and teamwork skills.
• Proficiency in nursing/medical databases and Microsoft programs.

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).
• Coordinating integrated care plan development, including collaboration with nursing staff and the 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 experience

Case management

Interdisciplinary teamwork

Medicare knowledge

Communication skills

Microsoft Office

EMR documentation

Critical thinking

Education

RN license

Tools

gEHRimed EMR

Job description

Provider Partners is seeking a Nurse Care Coordinator to support the PPHP Model of Care by assessing, planning, facilitating, coordinating, and advocating for services to meet the health needs of long-term care members with complex, chronic conditions.

You will partner with the Transitional Care Team and the interdisciplinary staff to identify needs, develop and document care plans, coordinate referrals, and promote high-quality, cost-effective outcomes.