This postion will support Wellsential Healthcare Skilled Nursing Facilites in the following locations: Robstown, Kingsville, Alice and San Diego.

Primary Responsibilities

The RNCC partners with the Texas Independence Health Plan Institutional Special Needs Plan (ISNP) Nurse Practitioner (Plan NP) to coordinate care for ISNP Beneficiaries (Plan Members), maintain routine contact with Plan Members, family, and facility staff, and inform Plan NPs and facility staff when there are potential medical, emotional, or behavioral changes in a Plan Member’s condition. Functions as a Case/Care Manager and patient healthcare navigator for Texas Independence Health Plan Members within nursing facilities. Weekend on-call support duties and all other duties as assigned.

Essential Functions

• Assist the Plan NP with care coordination duties and documentation on Plan Members. May initiate and, in some cases, complete assessments with Plan Members collecting vital signs and other administrative care plan data.
• Perform daily rounds to assess changes in Plan Members’ conditions and obtain a daily Plan Member census evaluation, documenting and reporting to Plan NPs and RNPs which Plan Members were transferred out of the Facility (to the Emergency Department or for Hospitalization), who elected Hospice Care, and who returned from the Hospital in the past 24 hours.
• Partner with facility staff and other members of the Interdisciplinary Care Team (ICT) to implement care plans for Plan Members and identify and assist in coordinating specialty or ancillary services, therapy, and other referral needs.
• Monitor Plan Members experiencing changes in condition and transitions to and from the hospital or other healthcare environment by coordinating with facility staff to stay in touch with the hospital for updates and informing the Plan NP of the Plan Member’s hospitalized status. Ensure the Plan NP receives the Plan Member’s discharge paperwork and summary.
• Follow up (in person) timely with each Plan Member after a transition to ensure that the Plan Member is not at risk for readmission and to inform the Plan NP of any possible medical or other needs the Plan Member may have.

Educational/Training Requirements

ADN, current Board Certification

Licensing Requirements

RN

Travel Requirements:

Must have reliable transportation to be able to travel to assigned locations.

Experience Requirements

The RNCC will comply with all State and Federal guidelines required to practice as a licensed Registered Nurse, including maintaining an active RN license in the state of Texas. The RNCC is responsible for maintaining ongoing Texas Board of Nursing educational requirements for licensure and re-certification.

• Alert the Plan NP promptly of new enrollees and place urgency on the Plan NP’s intervention if the Plan Member is at risk for transition at any time.
• Perform all other duties congruent with the ISNP Plan as assigned.

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Medical specialties:

• Geriatrics

Physical setting:

• Long term care
• Nursing home
• Rehabilitation center

Standard shift:

• Day shift

Supplemental schedule:

• On call

Weekly schedule:

• Monday to Friday

Work Location: In person