RN Care Coordinator- SNF/LTC
On-site · Philadelphia, Pennsylvania, United States
Job Summary
Nurse Care Coordinator for PPHP Model of Care in a Skilled Nursing Facility/Long-Term Care setting. Responsible for assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet the comprehensive health needs of PPHP members. Performs risk stratification, collaborates with the Transitional Care Team to reduce readmissions, conducts holistic assessments of medical/social barriers, develops integrated care plans with nursing leadership and interdisciplinary teams, facilitates referrals/consultations, documents care plans in the gEHRimed EMR, manages outcomes against goals, and ensures Model of Care training for staff and contracted personnel.
Required Qualifications
- Current unrestricted RN license for the state of practice
- Minimum of 3 years clinical care experience
- Knowledge of Medicare/Medicaid
- Strong ability to work with interdisciplinary team
- Proficiency in nursing/medical databases and Microsoft programs
- Excellent independent critical thinking and problem-solving skills
- Excellent oral and written interpersonal communication, organizational, multitasking, and teamwork skills
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