RN Care Coordinator-

$84,000 - $86,000/Yr

Provider Partners Health Plan - Winston-Salem, NC

Full-time - Mid Level

Onsite - Winston-Salem, NC

Ambulatory Health Care Services

About the position

The RN Care Coordinator will be instrumental in executing the Provider Partners Health Plan (PPHP) Model of Care (MOC) by assessing, planning, facilitating, coordinating care, evaluating, and advocating for services to meet the health needs of PPHP members. This role emphasizes effective communication and resource utilization to promote quality and cost-effective outcomes, particularly for residents with complex and chronic conditions in long-term care settings.

Responsibilities

• Conduct case identification and risk stratification to determine the needs of PPHP members.
• Collaborate with the Transitional Care Team to minimize re-admissions and prevent unnecessary hospitalizations.
• Perform and document comprehensive assessments of barriers to care, including medical, social, psychosocial, and literacy factors.
• Develop integrated care plans in collaboration with nursing staff and the interdisciplinary team according to the PPHP MOC.
• Facilitate appropriate referrals and consultations as needed.
• Document care plans in the gEHRimed EMR system.
• Manage outcomes and evaluate the achievement of established goals within the care plan.
• Ensure initial and annual follow-up Model of Care training for employees, providers, and contracted personnel associated with the ISNP program.

Requirements

• Current unrestricted RN license for the state of practice.
• 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 communicate professionally with the interdisciplinary team.
• Excellent critical thinking and problem-solving skills.
• Strong oral and written communication, organizational, multi-tasking, and teamwork skills.
• Proficiency in nursing/medical databases and Microsoft programs.
• Valid driver's license and car insurance with reliable transportation.

Nice-to-haves

• Experience in long-term care (1 year preferred).
• Associate degree in nursing (preferred).

Benefits

• Health insurance
• Dental insurance
• 401(k)
• Paid time off
• Vision insurance