RN Care Coordinator-South Bend, Indiana (part-time)

Eventus WholeHealth Careers•South Bend, IN

9d•Onsite

About The Position

At Eventus WholeHealth, we believe in transforming healthcare delivery in skilled nursing and assisted living facilities through integrated, evidence-based care. Founded in 2014, our organization is committed to improving patient outcomes with a comprehensive, collaborative approach. We’re proud to offer a multidisciplinary team where we build meaningful partnerships with facilities and empower them to achieve their goals, while ensuring the highest standard of care for patients and residents. Our innovative platform leverages AI-driven tools to enhance clinical decision-making, streamline workflows, and support proactive, whole-person care. Join our growing team and become part of a healthcare model that truly makes a difference!

Requirements

Registered Nurse
2+ years’ experience in LTC/ALF setting
Computer skills and proficiency in MS Office, PCC and Matrix required
Effective verbal and written communication skills
Highly organized with confidential client material, appointment tracking and caseloads
Strong customer service skills, knowledge of geriatric population and patient navigation
Ability to work independently, deliver to deadlines, and effectively handle multiple priorities
Ability to solve problems with minimal direction
Great attention to detail and accuracy
Interest in working with geriatric clients
Knowledge of Chronic Conditions
Knowledge of medications and their uses

Nice To Haves

Experience in care coordination or case management is a plus

Responsibilities

Coordinate care management in collaboration with the Mid-Level Practitioner (MLP).
Ensure ICT meeting occur regularly and include the MLP, Provider Physician, RNCC, SNF staff and administrators, beneficiaries, and families.
Complete Health Risk Assessment within 30 days of enrollment for all new attributed members and update the HRA within 364 days of initial assessment.
Triage care needs based on the member’s HRA scores and information from other sources.
Educate skilled nursing facilities’ staff through ICT meetings and regular communications while onsite.
Provide in-service education to skilled nursing facilities’ staff relating to specific needs of the geriatric population including but not limited to polypharmacy, fall prevention, and wound care management.
Identify and address changes in member’s health status by being available on call when not at the skilled nursing facility during scheduled visits.
Participate in quality assurance initiatives as needed to contribute to the development and implementation of best practices.
Advocate, inform, and educate members and their families through regular meetings and discussions.
Maintain accurate and up- to-date documentation in electronic health record regarding assessments, care plans, progress notes, and communications with family and patients.
Participate in meetings to discuss quality metric goals and progress towards goals.
Develop a plan of care for each member in collaboration with the ICT team.
Authorize and facilitate access to all covered services.
Provide clinical care to members to evaluate progress, conduct physical exams, prescribe interventions, and communicate results to the SNF staff in concert with any other attending physicians or practitioners.
Oversee transitions of care with communication from hospital, provider, family, and skilled nursing facility.
Conduct follow-up assessments and ensure continuity of care post-discharge from hospital.
Obtain labs, diagnostic reports and consultation reports and review as needed with plan medical director and ICT.
Provide information and document decisions regarding Advance Directives.