ISNP Clinical Coordinator

About the role

The Institutional Special Needs Plan (ISNP) Clinical Coordinator is a health plan–employed registered nurse assigned on-site to a designated skilled nursing facility (SNF). The position serves as the clinical integration link among the member, the SNF care team, the Medical Provider or other treating practitioner(s), and the health plan. The coordinator supports implementation of the ISNP Model of Care through daily clinical surveillance, timely escalation of changes in condition, facilitation of practitioner services, interdisciplinary care coordination, transition follow-up, quality improvement, and utilization management support. The role promotes person-centered care, skilled-in-place treatment when clinically appropriate, closure of quality gaps, and prevention of avoidable emergency department visits and hospitalizations.

Responsibilities

• Provide on-site continuity of care and facilitate effective onboarding of new health plan members
• Educate and train facility staff on the ISNP model of care
• Access facility and Nascentia EMR data to ensure the clinical team understands member transition needs and communicates any need for network status or provider support
• Update member information for provider review and facilitate initial and ongoing provider visits
• Perform care coordination activities and assist in Utilization Review processes including data collection, analysis, and outcomes reporting
• Utilize standards of care, evidence-based practices, CMS and organizational coverage guidelines to assure members receive high-quality, cost-efficient care
• Perform utilization review in accordance with state-mandated regulations
• Facilitate telehealth visits with providers and patients with acute or ongoing needs
• Coordinate Plan of Care services with facility staff, patients, families, and providers
• Communicate with physicians, medical directors, and the interdisciplinary team to address symptoms and improve care
• Monitor 24-hour reports and prepare daily reports with huddle report-outs
• Evaluate patient health status, needs, and resources; develop and revise patient-centered care plans in collaboration with patients, families, and providers
• Arrange and schedule appointments, referrals, therapies, and follow-ups; coordinate clinical, psycho-social, and spiritual services as needed
• Act as a liaison between patients, families, and healthcare systems; ensure patient preferences and needs are met, including navigating insurance coverage and pre-approvals
• Provide information on disease management, medication use, self-care, and preventive measures to patients and caregivers
• Track progress, adjust care plans as needed, and update medical records to reflect changes
• Facilitate smooth transitions between healthcare settings
• Uphold state and federal regulations, safety standards, and ethical conduct
• Offer emotional and physical support to patients and families, especially during crises
• Discuss and explain advance care plan options and benefits; obtain informed consent
• Assist with review of member usage patterns for medical necessity and appropriateness
• Perform continuing review of medical records and supporting documentation for medical necessity where appropriate
• Track and analyze service utilization patterns monthly and compare to regional benchmarks
• Participate in interdisciplinary collaboration with professional staff
• Perform concurrent, prior service authorizations and retrospective reviews
• Analyze per member per month (PMPM) data
• Educate and promote the ISNP Model of Care with staff, patients, and families

Qualifications

• Current NYS RN licensure
• BSN preferred
• Three or more years of home health care or long-term care experience strongly preferred
• Three or more years of utilization management or quality improvement experience preferred
• Experience with CMS regulatory requirements

Skills and Abilities

• Excellent relational communication and management skills
• Demonstrates professional decorum
• Demonstrated ability to problem-solve complex, multifaceted situations
• Successfully manage conflict and negotiate solution-focused outcomes
• Strong organizational, prioritizing, and delegation skills
• Strong critical thinking and ability to anticipate change
• Strong written and verbal communication skills
• Advocacy-focused
• Computer literacy with Microsoft Office products

Physical Requirements

• Speech, visual, and hearing ability sufficient to express and comprehend written and verbal communication
• Ability to sit or stand 90% of the day
• Frequent sitting, standing, and walking
• Pushing, pulling, reaching, and kneeling
• Bloodborne Pathogens Exposure Determination Category: Category III – Employee who rarely has contact with blood and body fluids

Pay

Competitive salary for an S03 exempt position with a range of $75,250 – $87,138.92 annually.

Benefits

• Retention bonuses
• Eligible site for the Nurse Corps Loan Repayment Program
• Internal mentoring program
• 401(k) with generous employer match
• On-site gym (free for all employees)
• Excellent work/life balance (no rotating shifts; only 2 required holidays per year on a rotating schedule)
• Medical, dental, and vision plans
• Tuition reimbursement (BSN after only 6 months of employment)
• Partially funded HSA
• Employee recognition platform
• Paid time off, holidays, sick and extended sick leave
• Short- and long-term disability
• Employee Assistance Program (EAP)