RN Care Coordinator-Indiana

About the role

Coordinate care management in collaboration with the Mid-Level Practitioner (MLP). Ensure ICT meetings occur regularly and include the MLP, Provider Physician, RNCC, SNF staff and administrators, beneficiaries, and families. Complete Health Risk Assessment within 30 days of enrollment for all new attributed members and update the HRA within 364 days of initial assessment. Triage care needs based on the member’s HRA scores and information from other sources.

Responsibilities

• Educate skilled nursing facilities’ staff through ICT meetings and regular communications while onsite.
• Provide in-service education to skilled nursing facilities’ staff relating to specific needs of the geriatric population including but not limited to polypharmacy, fall prevention, and wound care management.
• Identify and address changes in member’s health status by being available on call when not at the skilled nursing facility during scheduled visits.
• Participate in quality assurance initiatives as needed to contribute to the development and implementation of best practices.
• Advocate, inform, and educate members and their families through regular meetings and discussions.
• Maintain accurate and up-to date documentation in electronic health record regarding assessments, care plans, progress notes, and communications with family and patients.
• Participate in meetings to discuss quality metric goals and progress towards goals.

Requirements

2+ years’ experience in LTC/ALF setting
Computer skills and proficiency in MS Office, PCC and Matrix required
Experience in care coordination or case management is a plus

Skills

• Effective verbal and written communication skills
• Highly organized with confidential client material, appointment tracking and caseloads
• Strong customer service skills, knowledge of geriatric population and patient navigation
• Ability to work independently, deliver to deadlines, and effectively handle multiple priorities
• Ability to solve problems with minimal direction
• Great attention to detail and accuracy
• Interest in working with geriatric clients
• Knowledge of Chronic Conditions
• Knowledge of medications and their uses
• Develop a plan of care for each member in collaboration with the ICT team
• Authorize and facilitate access to all covered services
• Provide clinical care to members to evaluate progress, conduct physical exams, prescribe interventions, and communicate results to the SNF staff in concert with any other attending physicians or practitioners.
• Oversee transitions of care with communication from hospital, provider, family, and skilled nursing facility.
• Conduct follow-up assessments and ensure continuity of care post-discharge from hospital.
• Obtain labs, diagnostic reports and consultation reports and review as needed with plan medical director and ICT.
• Provide information and document decisions regarding Advance Directives

Benefits

AI-Enabled Innovation: Work with cutting-edge technology that enhances care delivery and operational efficiency.
Interdisciplinary Collaboration: Work closely with Advanced Practice Clinicians, Physicians, Behavioral Health professionals, and facility partners.
Mission-Driven Impact: Help redefine long-term care and improve lives every day.
Meaningful Impact: Your work directly enhances patient care, clinician experience, and facility partnership success.
Competitive Benefits: Employer paid employee medical benefits for qualifying roles, Paid Time Off + 8 Paid Holidays, Medical, dental, and vision insurance, HSA and FSA options, Employer-paid employee life insurance, Short-term / long-term disability options, Voluntary Life and AD&D Coverage, Employer 401(k) contributions, Fuel card for gas and car maintenance
Equal Opportunity Employer Statement: We are an equal opportunity employer and are committed to creating an inclusive environment for all employees. We consider all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other protected characteristic in accordance with applicable laws.

Pay

TBD

Schedule

TBD