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), maintaining routine contact with Plan Members, family, and facility staff, and informing Plan NPs and/or 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, as well as 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 has elected Hospice Care, and who has 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 the coordination of specialty or ancillary services, therapy, and/or other referral needs. Monitor Plan Members experiencing changes of condition, transitions to and from the hospital or other healthcare environment by working in coordination 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 that the Plan Member’s discharge paperwork and summary are received by the Plan NP. Follow-up (in person) timely with each Plan Member after a transition to ensure that the Plan Member is not at risk for a readmission and to inform the Plan NP of any possible medical or other needs the Plan Member may have. 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.