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, administrators, beneficiaries, and families.
Administrative Duties
Educate skilled nursing facility staff through ICT meetings and regular communications while onsite.
Provide in‑service education to skilled nursing facility staff on geriatric topics such as polypharmacy, fall prevention, and wound care management.
Identify and address changes in a member’s health status by being available on call during periods when not at the skilled nursing facility.
Participate in quality assurance initiatives to develop and implement best practices.
Advocate, inform, and educate members and their families through regular meetings and discussions.
Maintain accurate and up‑to‑date documentation in the electronic health record regarding assessments, care plans, progress notes, and communications.
Participate in meetings to discuss quality metric goals and progress towards those goals.
Transitions of Care
Oversee transitions of care with communication from hospital, provider, family, and skilled nursing facility.
Conduct follow‑up assessments and ensure continuity of care after hospital discharge.
Obtain labs, diagnostic reports, and consultation reports and review them as needed with the plan medical director and ICT.
Provide information and document decisions regarding advance directives.
Qualifications
Registered Nurse with requisite skills and qualifications.
At least 2 years of experience in LTC/ALF settings.
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, meet deadlines, and 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 and medications.
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 SNF staff in concert with other attending physicians or practitioners.