RN Care Coordinator-Indiana at Eventus WholeHealth
Loogootee, IN
Responsibilities
Coordinate care management in collaboration with the Mid‑Level Practitioner (MLP).
Ensure Integrated Care Team (ICT) meetings occur regularly and include the MLP, Provider Physician, RNCC, SNF staff, administrators, beneficiaries, and families.
Complete Health Risk Assessment within 30 days of enrollment for all new members and update the HRA within 364 days of the initial assessment.
Triage care needs based on the member’s HRA scores and information from additional sources.
Educate skilled nursing facilities’ staff through ICT meetings and regular on‑site communications.
Provide in‑service education on geriatric‑population needs such as polypharmacy, fall prevention, and wound‑care management.
Identify and address changes in a member’s health status by being available on call when not at the skilled nursing facility during scheduled visits.
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 with family and patients.
Participate in meetings to discuss quality‑metric goals and progress toward those goals.
Provide clinical care to members: evaluate progress, conduct physical exams, prescribe interventions, and communicate results to the SNF staff in concert with other attending physicians or practitioners.
Develop a plan of care for each member in collaboration with the ICT team.
Authorize and facilitate access to all covered services.
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 them as needed with the plan medical director and ICT.
Provide information and document decisions regarding advance directives.
Qualifications
Registered Nurse with applicable credentials.
Minimum of 2 years’ experience in LTC/ALF setting.
Computer skills and proficiency in MS Office, PCC, and Matrix.
Experience in care coordination or case management (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 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 their management.