RN Care Coordinator-Indiana

Client Caseload Management

• Coordinate care management in collaboration with the Mid-Level Practitioner (MLP).
• Ensure ICT meeting 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.

Administrative Duties

• 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.

Education And/Or Certifications

• Registered Nurse Skills and Qualifications
• 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
• 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.

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