RN Care Navigator for ISNP Members

Regency Integrated Health Services; Fort Worth (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Cityview Nursing and Rehabilitation Center in Fort Worth, TX seeks an RN Care Coordinator (RNCC) to partner with the Plan NP and coordinate care for ISNP beneficiaries in the nursing facility. The role involves routine member contact with families and staff, and alerting Plan NPs to potential changes in member condition.

The RNCC will participate in rounds, update care plans, and support transitions with hospital systems while ensuring timely follow-up and documentation.

Qualifications

• ADN degree required; RN license in Texas.
• Experience in care coordination within a nursing facility.
• Proficient with documenting in EHR and care plans.

Responsibilities

• Assist the Plan NP with care coordination and documentation; participate in rounds.
• Perform daily rounds and census evaluations; report changes to Plan NPs.
• Collaborate with the ICT to implement care plans and coordinate services.
• Monitor transitions to hospital and communicate status; ensure discharge paperwork is received.
• Follow up in person after transitions to prevent readmission; address patient needs.
• Notify Plan NP of new enrollees and urgent needs; perform other ISNP Plan duties as assigned.

Skills

Care coordination

Assessment

Documentation

Team collaboration

Nursing knowledge

Education

ADN

Tools

EHR systems

Hospital information systems

Job description

Cityview Nursing and Rehabilitation Center in Fort Worth, TX seeks an RN Care Coordinator (RNCC) to partner with the Plan NP and coordinate care for ISNP beneficiaries in the nursing facility. The role involves routine member contact with families and staff, and alerting Plan NPs to potential changes in member condition.

The RNCC will participate in rounds, update care plans, and support transitions with hospital systems while ensuring timely follow-up and documentation.