Current jobs related to Skilled Nursing Transitions Coordinator - Plymouth - Harbor Health Services
-
Care Coordinator
1 month ago
Plymouth Meeting, Pennsylvania, United States ProgenyHealth Full timeJob Title: Care CoordinatorProgenyHealth is a leading provider of care management solutions for infants in intensive care nurseries. We partner with health plans and employer groups to deliver high-quality care to our members.Job SummaryWe are seeking a skilled Care Coordinator to join our team. As a Care Coordinator, you will be responsible for initiating...
-
Travel Nurse RN Skilled Nursing Position
1 month ago
Plymouth, Wisconsin, United States NuWest Travel Nursing Full timeJob Title: Travel Nurse RN Skilled NursingNuWest Travel Nursing is seeking a skilled nursing professional to join their team as a travel nurse RN.Job DetailsSpecialty: Skilled NursingDiscipline: RNEmployment Type: TravelPerks: Competitive pay, benefits, and relocation assistanceNuWest Travel Nursing offers a range of benefits, including medical, dental,...
-
Travel Nurse RN Skilled Nursing Position
1 month ago
Plymouth, Wisconsin, United States NuWest Travel Nursing Full timeJob DetailsNuWest Travel Nursing is seeking a skilled nursing professional for a travel nursing assignment in Wisconsin.Job RequirementsSpecialty: Skilled NursingDiscipline: RNEmployment Type: TravelPerks: Competitive pay, benefits, and relocation assistance available.This travel nursing position offers a unique opportunity to work in a skilled nursing...
-
Pre-Employment Transition Services Counselor
1 week ago
Plymouth, Massachusetts, United States Tempus Unlimited Inc. Full timeJob SummaryTempus Unlimited Inc. is seeking a highly motivated and experienced Pre-Employment Transition Services Counselor to join our team. As a key member of our employment services team, you will be responsible for providing pre-employment skills training and support to high school students with disabilities, with the goal of securing internships and...
-
Pre-Employment Transition Services Counselor
4 weeks ago
Plymouth, Massachusetts, United States Tempus Unlimited Inc. Full timeJob Title: Pre-Employment Transition Services CounselorTempus Unlimited, Inc. is a nonprofit organization dedicated to empowering individuals with disabilities to live independently and participate fully in their communities. We are seeking a highly motivated and experienced Pre-Employment Transition Services Counselor to join our team.Job Summary:The...
-
Plymouth, Wisconsin, United States NuWest Travel Nursing Full timeJob Opportunity for Travel Nurse RNNuWest Travel Nursing is seeking a skilled travel nurse RN for a long term care position in Plymouth, Wisconsin.Specialty: Long Term CareDiscipline: RNShift: 8 hours, nightsEmployment Type: TravelPerks: Benefits include medical, dental, vision, 401K, weekly direct deposit, and moreBenefits include medical, dental, vision,...
-
Social Services Coordinator
3 weeks ago
Plymouth, Michigan, United States SKLD Plymouth Full timeJob Title: Social Services CoordinatorAt SKLD Plymouth, we are seeking a highly skilled and compassionate Social Services Coordinator to join our team. As a key member of our Social Services Department, you will play a vital role in ensuring the well-being and quality of life for our residents.Key Responsibilities:Conduct thorough assessments of residents'...
-
Social Services Coordinator
3 weeks ago
Plymouth, Michigan, United States SKLD Plymouth Full timeJob SummaryWe are seeking a highly skilled and compassionate Social Services Coordinator to join our team at SKLD Plymouth. As a key member of our care team, you will play a vital role in ensuring the well-being and quality of life for our residents.Key ResponsibilitiesConduct thorough assessments of residents' social and economic needs, identifying areas...
-
Social Services Coordinator
3 weeks ago
Plymouth, Michigan, United States SKLD Plymouth Full timeJob SummaryWe are seeking a highly skilled and compassionate Social Services Coordinator to join our team at SKLD Plymouth. As a key member of our Social Services Department, you will play a vital role in ensuring the well-being and quality of life for our residents.Key ResponsibilitiesConduct thorough assessments of residents' social and economic needs,...
-
Social Services Coordinator
3 weeks ago
Plymouth, Michigan, United States SKLD Plymouth Full timeJob SummaryWe are seeking a highly skilled and compassionate Social Services Coordinator to join our team at SKLD Plymouth. As a key member of our Social Services Department, you will play a vital role in ensuring the well-being and quality of life for our residents.Key ResponsibilitiesConduct thorough assessments of residents' social and economic needs,...
-
Social Services Coordinator
1 week ago
Plymouth, Michigan, United States Plymouth Court SNF, LLC Full timeJob Title: Social Services CoordinatorPlymouth Court SNF, LLC is seeking a highly skilled and compassionate Social Services Coordinator to join our team. As a key member of our care team, you will play a vital role in ensuring the social and emotional well-being of our residents.Key Responsibilities:Conduct thorough assessments of residents' social and...
-
MDS Nurse
1 week ago
Plymouth, Massachusetts, United States MVP Recruitment, LLC Full timeJob OverviewMVP Recruitment, LLC is excited to present a fantastic opportunity for a dedicated MDS Nurse at a beautiful Skilled Nursing Facility located in a desirable area. This full-time role is an integral part of a busy and well-respected facility that provides both skilled services and long-term care.As an MDS Nurse, you will be responsible for...
-
Plymouth, Wisconsin, United States NuWest Travel Nursing Full timeNuWest Travel Nursing is seeking a skilled travel nurse RN for a long term care position in a skilled nursing facility.Job DetailsSpecialty: Long Term CareDiscipline: RNShift: 8 hours, nightsEmployment Type: TravelPerks: Benefits include medical, dental, vision, 401K, weekly direct deposit, and moreBenefits include medical, dental, vision, 401K, weekly...
-
Emergency Department Case Manager
4 weeks ago
Plymouth, Massachusetts, United States Beth Israel Deaconess Hospital-Plymouth Full timeJob SummaryBeth Israel Deaconess Hospital-Plymouth is seeking a skilled Emergency Department Case Manager to join our team. As a key member of our care transitions department, you will play a critical role in improving patient outcomes, reducing length of stay, and decreasing unit cost.Key ResponsibilitiesUtilization Management: Review anticipated...
-
Youth Advocate Coordinator
2 weeks ago
Plymouth, Massachusetts, United States Eliot's Full timeJob Title: Youth Advocate CoordinatorEliot's juvenile justice program is seeking a dedicated and experienced Youth Advocate Coordinator to join our team. As a key member of our residential network, you will play a vital role in providing daily coordination of direct-care staff and youth in executing the plan of the day.Responsibilities:Coordinate daily...
-
Licensed Practical Nurse
7 days ago
Plymouth, Wisconsin, United States Plymouth Health Services Full timePlymouth Health Services is a leading provider of skilled nursing and rehabilitation in your community. As a member of the North Shore Healthcare family, we are part of the largest post-acute provider in the Upper Midwest with 70 skilled nursing and assisted living centers located throughout Wisconsin, Minnesota, Michigan, and North Dakota.Our center is...
-
Occupational Therapist
1 week ago
Plymouth, Massachusetts, United States Aequor Technologies Full timeAbout the Role We are seeking an experienced Occupational Therapist (OT) to join our team at Aequor Technologies. As an OT, you will play a vital role in helping patients regain or improve their independence in daily activities within a Skilled Nursing Facility (SNF) setting. Key Responsibilities Assess patients' physical and mental abilities to determine...
-
Nurse
4 weeks ago
Plymouth, Massachusetts, United States IntelyCare Full timeJob Title: Registered Nurse (RN)Are you a compassionate and skilled Registered Nurse (RN) looking for a new challenge? Do you want to work in a dynamic and supportive environment where you can make a real difference in the lives of others? Look no further than IntelyCare, a leading provider of post-acute care services.About the Job:We are seeking a highly...
-
Occupational Therapist
2 weeks ago
Plymouth, Massachusetts, United States Aequor Technologies Full timeAbout the JobAequor Technologies is seeking an experienced Occupational Therapist (OT) to join our team in a Skilled Nursing Facility (SNF) setting. As an OT, you will play a vital role in helping patients regain or improve their independence in daily activities.Job ResponsibilitiesAssess patients' physical and mental abilities to determine rehabilitation...
-
Family Practice Nurse Practitioner
4 weeks ago
Plymouth, Utah, United States CareATC Full timeFamily Practice/Primary Care Nurse Practitioner OpportunityWe are seeking a highly skilled Family Practice/Primary Care Nurse Practitioner to join our team at CareATC. As a key member of our healthcare team, you will provide high-quality patient care and work collaboratively with our physicians and staff to deliver exceptional patient outcomes.Key...
Skilled Nursing Transitions Coordinator
2 months ago
Harbor Health operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly, a program that allows frail elders to live in their homes and communities. Our Elder Service Plan has two medical and day centers in Mattapan and Brockton, MA and cares for more than 580 participants. we are seeking a SkilledNursing Transitions Coordinator to join our team at the Elder Service Plan (a PACE Program) in Brockton.
Harbor Health offers an excellent, comprehensive benefits package including Health, Dental, Vision, Life, & Disability insurance, 403b Savings Plan, Generous Paid Time Off plus 11 additional Holidays and much more
Role:
Under the general direction of the Director of Care Coordination, the Skilled Nursing Transitions Coordinator partners with the Interdisciplinary Team (IDT) to facilitate the progression of care for Harbor PACE Elder Service Plan (ESP) participants in short term rehabilitative, skilled nursing, and long-term acute care facilities. Using a collaborative approach, the Interdisciplinary Team focuses on delivery of efficient, high quality rehabilitative and skilled nursing care. The Care Transitions Case Manager ensures appropriate utilization of skilled nursing resources with a goal of safe and timely discharge for the Harbor ESP participants and navigates and utilizes ESP services to support effective transitions. Our ideal candidate must be adept at utilization review, care coordination, discharge planning, fiscal responsibility, and relationship development.
Responsibilities:
- Works in close collaboration with other members of the Interdisciplinary and Utilization Management team around all Subacute, Skilled Nursing Facility (SNF), and Long Term Acute Care (LTAC) transitions.
- Serves as a collaborative bridge between ESP and SNFs.
- Performs prospective, concurrent, and retrospective utilization management-related reviews and ensures all data are tracked, evaluated, and reported.
- Utilizes clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
- Collaborates with ESP interdisciplinary teams and subacute/skilled nursing facilities regarding management of members not meeting continuing stay criteria.
- Obtains and communicates clinical information effectively to participant, family/caregiver, Interdisciplinary Team and SNF/Subacute facility.
- Works collaboratively with Utilization Management Nurses and Care Coordinators to ensure facilities have all information and paperwork needed to care for the participant at the time of admission.
- Authorizes length of stay appropriate for condition and level of function and communicates to appropriate facility.
- Actively seeks clinical documentation and reviews all assessments and clinical information for every active SNF/Subacute/LTAC stay and ensures ESP has comprehensive Electronic Health Record (EHR) records.
- Supports different disciplines in overcoming barriers to discharge, including housing, functional needs, and caregiver support.
- Serves as conduit for family and home facility (e.g., ALF) communication for discharge planning.
- Develops trusted relationships with SNFs, including attending meetings and routine site visits to contracted facilities.
- Maintains tight control of active SNF/LTAC caseload, knows goals to discharge, barriers, etc., escalates issues on team meetings, follows action items to completion and supports IDT members needing access to SNF information.
- Facilitates All-Teams SNF weekly utilization review meetings with IDT including prepares and maintains meeting spreadsheets for effective meeting management, ensures action items are addressed, communicates planned discharge dates, sends updated authorizations and additional pertinent information as needed to respective SNF/Subacute facilities.
- Responsible for reviewing, close monitoring and authorizations for add-on charges for participants in long term care when appropriate.
- Responsible for obtaining the information necessary to assess a participants clinical condition, identifies ongoing clinical care needs and ensures that participants receive services in the most optimal setting to effectively meet their needs.
- Ensures all services needed for safe discharge are in place including Home Health Aides/Caregivers, nursing, Durable Medical Equipment (DME), rehab, transportation, family, etc., ensures Discharge Summary with medication list is obtained and as appropriate, completes assessment tools and enters orders (e.g., DME, home health aides, etc.).
- Triggers Change of Status actions when participants are unable to return home.
- Conducts regular and as-needed in-person visits to contracted Skilled Nursing Facilities for relationship-building, resident visits, quality checking, etc.
- Uses Patient Ping to track participant disposition.
Requirements:
- Associate in nursing (ADN) required, BSN preferred or degree in other discipline as indicated by licensure (see substitutions)
- Current, valid, and unrestricted Registered Nurse (R.N.) license or other valid MA license as indicated in substitutions
- Substitutions for RN license:
- LPN (Licensed Practical Nurse) with 4 additional years of Skilled Nursing Facility experience
- Registered Physical or Occupational Therapist (PT/OT)
- OTA/PTA with 4 additional years of Skilled Nursing Facility experience.
- Current BLS (Basic Life Support for Health Care Providers) Certification
- Current, valid, and unrestricted MA Registered Nurse (R.N.) license.
- 2 years of experience in a Skilled Nursing Facility as Staff Nurse, Nurse Case Manager, Nurse discharge planner or clinical manager
- 2 years of experience working in geriatric care
- Experience with hospital discharge and/or home care experience preferred
- Proficient in Microsoft Office 365 skills to include in Word, Excel, Outlook and Teams, database use, Nursing Home Electronic Health Records, and data entry
- Demonstrated ability to run effective meetings both virtual and in-person.
- Must be able to travel between two or more sites and to outside contract agencies in a timely manner.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
