The Institutional Special Needs Plan (ISNP) Clinical Coordinator is a health plan-employed registered nurse assigned on-site to a designated skilled nursing facility (SNF). The position serves as the clinical integration link among the member, the SNF care team, the Medical Provider or other treating practitioner(s), and the health plan. The coordinator supports implementation of the ISNP Model of Care through daily clinical surveillance, timely escalation of changes in condition, facilitation of practitioner services, interdisciplinary care coordination, transition follow-up, quality improvement, and utilization management support. The role promotes person-centered care, skilled-in-place treatment when clinically appropriate, closure of quality gaps, and prevention of avoidable emergency department visits and hospitalizations.

The ISNP Clinical Coordinator is assigned to Nascentia Health Members for the purpose of executing the Institutional Special Needs Model of Care within a Skilled Nursing Facility. The coordinator is responsible for supporting on site continuity of care, data gathering and facilitation of effective onboarding of new health plan members. The coordinator will work with the local clinical and administrative staff to educate and train the nursing facility on the ISNP model of care, will access facility and Nascentia EMR data to ensure the Nascentia clinical team understands member transition needs and communicates any need for network status or other provider support. Additionally, the coordinator will update member information for provider review, facilitate initial and ongoing provider visits, and perform care coordination activities. The coordinator will also assist in Utilization Review processes including data collection of demographics, claims, and medical information; analysis; and outcomes reporting. Utilize standards of care, evidence-based practices, CMS and organizational coverage guidelines to assure members receive high-quality, cost-efficient health care and services to meet their long-term home and community-based needs. Performs utilization review in accordance with all state-mandated regulations.

This position is Full-Time, Monday through Friday, 8 am-4:30 pm on-site at a designated SNF.

Performance Responsibilities and Standards:

1. Performs facilitated Telehealth visits with provider and patients with acute or on-going needs
2. Coordinates Plan of Care services with facility staff, patient, families and providers
3. Communicate with physicians, medical directors, and the interdisciplinary team to address symptoms and improve care
4. Monitor 24-hour reports and prepare daily reports with report out at huddles
5. Assessment & Planning: Evaluate patient health status, needs, and resources; develop and revise patient-centered care plans in collaboration with patients, families, and providers
6. Coordination: Arrange and schedule appointments, referrals, therapies, and follow-ups; coordinate clinical, psycho-social, and spiritual services as needed
7. Advocacy: Act as a liaison between patients, families, and healthcare systems; ensure patient preferences and needs are met, including navigating insurance coverage and pre-approvals
8. Education: Provide information on disease management, medication use, self-care, and preventive measures to patients and caregivers
9. Monitoring & Adjustment: Track progress, adjust care plans as needed, and update medical records to reflect changes
10. Transition Care: Facilitate smooth transitions between healthcare settings (e.g., hospital to home.
11. Compliance: Uphold state and federal regulations, safety standards, and ethical conduct
12. Support: Offer emotional and physical support to patients and families, especially during crises
13. Discuss and explain advance care plan options and benefits; obtain informed consent.
14. Assist with the review of member usage patterns for medical necessity and appropriateness.
15. Perform continuing review of medical records and supporting documentation for medical necessity where appropriate.
16. Tracks and analyzes service utilization patterns monthly and compares to regional benchmarks
17. Participates in interdisciplinary collaboration with professional staff.
18. Performs concurrent, prior service authorizations and retrospective reviews
19. Analyze per member per month (PMPM) data
20. Educate and promote the ISNP MOC with staff, patients and families
21. Other duties as assigned

Job Qualifications:

1. Current NYS RN licensure, BSN preferred.
2. Three or more years of home health care or long-term care experience is strongly preferred.
3. Three or more years of utilization management or quality improvement experience preferred.
4. Experience with CMS regulatory requirements.

Professional competencies, skills, and abilities:

1. Excellent relational communication and management skills
2. Demonstrates professional decorum
3. Demonstrated ability to problem-solve complex, multifaceted situations
4. Successfully manage conflict and negotiate solution focused outcomes
5. Strong organizational, prioritizing, and delegation skills
6. Strong critical thinking and ability to anticipate change
7. Strong communication skills written and verbal
8. Advocacy focused
9. Computer literacy with Microsoft Office products

Physical Requirements:

1. Speech, visual, and hearing ability sufficient to express and comprehend written and

verbal communication

1. Ability to sit or stand 90% of the day
2. Frequent sitting, standing, walking
3. Pushing, pulling, reaching, kneeling
4. Bloodborne Pathogens Exposure Determination Category: Category III- Employee who rarely has contact with blood and body fluids.

Compensation & Benefits:

Competitive Salary [This position is an S03 exempt position with a min-max rate of: $75,250- $87,138.92/annually] with:

• Retention Bonuses
• • Eligible Site for the Nurse Corps Loan Repayment Program
• Internal Mentoring Program
• 401K with generous Employer match
• On-Site Gym (free for all employees)
• Excellent work/life balance (no rotating shifts, only 2 required holidays per year on a rotating schedule)
• Medical, Dental, Vision plans
• Tuition Reimbursement (BSN after only 6 months of employment!)
• Partially funded HSA
• Employee Recognition Platform
• Paid Time Off, Holidays, Sick and Extended Sick Leave
• Short/Long term Disability
• Employee Assistance Program (EAP)
• Much More!

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About Nascentia Health:

Nascentia Health is leading the way in home care, post acute care and long-term community health. A healthcare system without walls, Nascentia is an innovator in the concept of healthcare, truly focused on the patient as a whole. By serving people in their homes, Nascentia Health is able to provide true holistic care. We can address immediate needs, help support positive long term medical and lifestyle choices that provide for better outcomes, leverage cutting edge in-home care technologies, and help avoid unnecessary visits to busy healthcare facilities.

Our employees are our greatest asset. They work hard every day to make our system amazing and are dedicated to our mission of being the premier home and community-based care system for the regions we serve. We want everyone to love what they do, be excited about coming to work, and take pride in being part of our team.

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Nascentia Health is an Equal Opportunity Employer (EOE)

Employment is contingent upon negative results of a pre-hire drug screen and background check