ISNP Clinical Coordinator

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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.

• 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…