Provider Partners Health Plan Verified
Hospitals and Health Care
RN Care Coordinator -LTC/SNF/ALF
Jasper, INOnsiteFull TimePosted 1 month ago
Required skills
- RN license
- clinical care experience
- Medicare/Medicaid
- interdisciplinary team
- nursing/medical databases
- Microsoft programs
- gEHRimed EMR
- care plan development
- risk stratification
- case identification
Nice to have
- Skilled Nursing Facility
- Long-Term Care
- ALF
- Case management
- complex cases
Role summary
The Nurse Care Coordinator will be instrumental in executing the Provider Partners Health Plan (PPHP) Model of Care (MOC). This role involves a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet the comprehensive health needs of PPHP program members. The coordinator will focus on promoting quality, cost-effective outcomes and managing care for residents with complex chronic conditions, aiming to reduce re-admissions and hospitalizations.
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.
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.
