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Registered Nurse - Service Coordinator - Nursing Homes
Service Coordinator is responsible for assessing member's functional and medical needs to collaborate with providers and coordinate and case/care management to STAR+PLUS and/or MMP Members residing in Nursing Facilities. The Service Coordinator has an overarching philosophy of providing quality care in the least restrictive environment promoting independent living, self-determination, and community integration.
Primary Duties and Responsibilities:
Conducts a comprehensive F2F (Nursing Facility assessments) 4 times per year with Members residing in a Skilled Nursing Facility.
Attends and actively participates in Nursing Facility care plan meetings for assigned Members to collaborate with nursing facility staff to mitigate barriers to care and prevent hospitalizations.
Collaborates with transition team to create a viable discharge plan for members expressing desire to return to the community through MFP process.
Works with member, member's family, nursing facility and providers to develop a comprehensive
Individualized service plan.
Uses clinical judgment to identify physical and behavioral health needs and works with the member and caregiver to establish an appropriate plan of care to ensure needs are met.
Works with member to close functional, clinical, and pharmacy gaps.
Acts as a liaison and facilitates the coordination of benefits, resources, healthcare providers, and institutions.
Completes and files all assessments within the timelines outlined by the state.
Maintains a maximum weekly face to face visit schedule of twelve members with average caseload of 120.
Strong organizational and time management skills
Must have strong computer skills using MS office products including Word, Excel, and Outlook
Excellent verbal and written communication skills
Must have reliable transportation, a valid and unrestricted driver's license and proof of insurance.
The ability to travel to members' homes, and other locations within the service delivery area.
Must be a Registered Nurse with a current, unrestricted Texas License
Previous STAR+PLUS experience.
Home Health Case Management experience with Medicare or Medicaid populations a plus
Experience managing members with chronic disease processes and
Experience working with community resource organizations preferred
Experience with care management software applications preferred.
# of Positions: 2
2208 North Highway 121, STE 210
Start Date: 01/28/2019
End Date: 03/30/2019
Hours Per Week: 40.00
Hours Per Day: 8.00
Monday through Friday 8 am through 5 pm
Job Type: Contract
Salary: $41.00 /year