(Archived) RN Care Coordinator

Job Description

The Nurse Care Coordinator will play a key role in the execution of the Model of Care 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 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. Additional responsibilities include:

• Case identification/risk stratification to establish needs of the patient.
• 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 patients plan of care.
• Coordinating integrated care plan development, including collaboration with nursing staff, leadership, as well as the entire interdisciplinary team.
• Facilitation of developing appropriate referrals/consultations.
• Documentation of care plans in EMR.
• Outcomes management and evaluation of the achievement of established goals within the plan of care.
  

Requirements:

• 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.
• Detailed knowledge of I-SNP MOC and I-SNP population.
• 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.