RN Care Coordinator

Registered Nurse Care Coordinator will support Simpra Nurse Practitioners in the to provide care management services for Simpra I-SNP, IE-SNP, and D-SNP Members, including direct clinical support, Member/ family/ representative engagement, advanced care planning, and facility education and training. Simpra offers Medicare Advantage Special Needs Plans with Members in nursing homes, assisted living facilities, specialty care assisted living facilities, and other communities in Alabama.

Job responsibilities:

· Promotes Member health by identifying changes in condition through excellent assessment skills.

· Develops a prioritized, Individualized Care Plan (ICP) based upon assessment findings and continually revises and updates the plan as needed.

· Collaborates with facility nursing staff and Simpra Nurse Practitioner (NP) to facilitate early recognition and treatment for changes in condition to help prevent unnecessary transfers to the hospital which includes ensuring diagnostic tests and consultations are ordered, completed, and reviewed timely. May attend morning meetings or round on Members, as needed. May attend other required meetings to support needs of Members. Discusses Members weekly with the NP to establish a schedule of visits based on Member acuity.

· Establishes self as the Simpra Members’ primary plan care manager for transitions in care:

o Ensuring safe and effective care transitions (prior/ during/ post transitions)

o Coordinating the care transition process

o Ensuring the transition of care protocols are followed

o Communicating with the Member, the representative, the caregiver/ family, the doctors, and nursing facility staff

· Assesses quality of care and works to close gaps identified in the healthcare effectiveness data and information set (HEDIS).

· Serves as the primary point of contact for Simpra Members, their representatives, and families, answering questions, addressing concerns, and fostering advanced care planning.

· Establishes a compassionate environment offering emotional, psychological, and spiritual support.

· Establishes collaborative relationships with facility staff to develop multidisciplinary team strategies to resolve Member concerns and needs.

· Identifies and responds to opportunities for improvement through facility staff training using the “Just In Time” learning method.

· Timely and accurately documents Members’ services in the Simpra care management system.

· Helps maintain continuity of care among staff by documenting and communicating actions, irregularities, and continuing needs as identified in the plan Model of Care (MOC).

· Complies with the HIPAA Privacy Rule and other applicable confidentiality policies and procedures.

· Maintains professional and technical expertise by maintaining nursing license, completing required continuing education, and participating in professional societies.

· Maintains a cooperative relationship among Simpra clinical team by communicating information and participating in team problem-solving methods.

· Initiates and organizes Interdisciplinary Care Team (ICT) meetings when needed. Also attends facility-scheduled meetings, serving as a liaison between the ICT and the NP/PCP.

Qualifications/ Skills:

• Exceptional assessment and critical thinking skills
• Effective organizational and autonomy skills; adept at coordinating diverse work groups
• Excellent verbal, written, and telehealth communication skills
• Comprehensive knowledge of care transition protocols
• Strong leadership qualities; able to work as a member of a team and drive activity simultaneously
• Comfortable working in a remote office environment
• Energetic promoter of quality health care and positive Member experience
• Proficient in clinical documentation

Education, Experience, and Licensing requirements:

• Registered Nurse (RN), BSN preferred
• Active Alabama Board of Nursing state licensure
• 5 years’ experience in nursing
• Experience in Medicare Advantage SNPs preferred
• Knowledge of geriatrics/long term care preferred
• Hospice/palliative care experience, case management experience, hospital/ER/critical care experience all would be considered advantageous

Job Type: Full-time

Pay: $75,000.00 per year

Benefits:

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

Medical Specialty:

• Geriatrics

Physical Setting:

• Long term care

Work Location: In person

Salary : $75,000