RN Care Coordinator -LTC/SNF-Springfield

Job Summary:
The Nurse Care Coordinator will play a key role in the execution of the Provider Partners Health
Plan (PPHP) Model of Care (MOC) through the collaborative process of assessment, planning,
facilitation, care coordination, evaluation, and advocacy for options and services to meet the
comprehensive health needs of each member of the PPHP program. Utilizing effective
communication skills and available resources, the Nurse Care Coordinator will promote quality,
cost-effective outcomes, including care coordination for complex and multiple chronic
conditions of the long-term care resident.
Key Responsibilities:
• Case identification/risk stratification to establish needs of the PPHP member.
• Collaboration with the Transitional Care Team to reduce re-admissions/avoid inappropriate
hospitalizations.
• Conducting and documenting a comprehensive assessment of barriers to care (medical, social,
psychosocial, and literacy) promoti...

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