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Performance Responsibilities and Standards:

Performs facilitated Telehealth visits with provider and patients with acute or on-going needs Coordinates Plan of Care services with facility staff, patient, families and providers Communicate with physicians, medical directors, and the interdisciplinary team to address symptoms and improve care Monitor 24-hour reports and prepare daily reports with report out at huddles

Assessment & Planning:

Evaluate patient health status, needs, and resources; develop and revise patient-centered care plans in collaboration with patients, families, and providers

Coordination:

Arrange and schedule appointments, referrals, therapies, and follow-ups; coordinate clinical, psycho-social, and spiritual services as needed

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

Education:

Provide information on disease management, medication use, self-care, and preventive measures to patients and caregivers

Monitoring & Adjustment:

Track progress, adjust care plans as needed, and update medical records to reflect changes

Transition Care:

Facilitate smooth transitions between healthcare settings (e.g., hospital to home.

Compliance:

Uphold state and federal regulations, safety standards, and ethical conduct

Support:

Offer emotional and physical support to patients and families, especially during crises Discuss and explain advance care plan options and benefits; obtain informed consent. Assist with the review of member usage patterns for medical necessity and appropriateness. Perform continuing review of medical records and supporting documentation for medical necessity where appropriate. Tracks and analyzes service utilization patterns monthly and compares to regional benchmarks Participates in interdisciplinary collaboration with professional staff. Performs concurrent, prior service authorizations and retrospective reviews Analyze per member per month (PMPM) data Educate and promote the

ISNP MOC

with staff, patients and families Other duties as assigned

Job Qualifications:

Current NYS RN licensure, BSN preferred. Three or more years of home health care or long-term care experience is strongly preferred. Three or more years of utilization management or quality improvement experience preferred. Experience with CMS regulatory requirements. Professional competencies, skills, and abilities: Excellent relational communication and management skills Demonstrates professional decorum Demonstrated ability to problem-solve complex, multifaceted situations Successfully manage conflict and negotiate solution focused outcomes Strong organizational, prioritizing, and delegation skills Strong critical thinking and ability to anticipate change Strong communication skills written and verbal Advocacy focused Computer literacy with Microsoft Office products

Physical Requirements:

Speech, visual, and hearing ability sufficient to express and comprehend written and verbal communication Ability to sit or stand 90% of the day Frequent sitting, standing, walking Pushing, pulling, reaching, kneeling

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! ________________________________________________

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. 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ISNP Clinical Coordinator