Provider Partners Health Plan·Philadelphia, Pennsylvania
The Nurse Care Coordinator executes the Provider Partners Health Plan Model of Care through assessment, planning, coordination, and evaluation to meet member health needs. This role involves promoting quality, cost-effective outcomes, especially for long-term care residents with complex chronic conditions.
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) promoting a holistic approach to developing the PPHP member’s plan of care. · Coordinating integrated care plan development, including collaboration with nursing staff, leadership, as well as the entire interdisciplinary team according to the PPHP MOC. · Facilitation of developing appropriate referrals/consultations. · Documentation of care plans in the gEHRimed EMR · Outcomes management and evaluation of the achievement of established goals within the plan of care. · Ensures initial and annual follow up Model of Care training occurs for employees, providers and contracted personnel associated with ISNP program
Candidates must possess a current unrestricted RN license and a minimum of three years of clinical care experience, with proficiency in managing complex cases independently. Preferred qualifications include experience in Skilled Nursing Facilities/Long Term Care and case management, along with knowledge of Medicare/Medicaid.
Market context
Pennsylvania nursing roles are typically in steady demand across hospitals, outpatient settings, and long-term care, especially for RNs with current state licensure and BLS certification. These positions are competitive because employers often prefer candidates with a BSN and recent medical-surgical experience, and this platform’s AI-summarized requirements and benefits help you review the original posting faster. Before applying, confirm your Pennsylvania RN license, BLS status, and whether your experience matches the unit’s preferred background.
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