POSITION/JOB SUMMARY:

• The RN Care Coordinator is responsible for assessing, coordinating, and evaluating individualized resident care to ensure quality outcomes and continuity of care. Responsibilities include comprehensive nursing assessments, care planning, care conferences, provider rounds, resident appointments, wound assessments, and clinical documentation oversight. This position collaborates with nursing staff, providers, families, the MDS Coordinator, and the interdisciplinary team to coordinate admissions, discharges, and ongoing resident care while ensuring compliance with facility policies and regulatory requirements.

This is a full-time (1.0 FTE), exempt position. The typical schedule is Monday through Frida

ESSENTIAL FUNCTIONS

• Complete comprehensive nursing assessments and develop, implement, monitor, and update individualized, person-centered care plans for assigned residents across all shifts in collaboration with the interdisciplinary team, hospital, and clinic to ensure resident needs are met.
• Ensures that the care plan is implemented and evaluates the effectiveness of the plan regularly in collaboration with the senior living team.
• Coordinate and participate in quarterly, annual, significant-change, and as-needed care conferences, ensuring resident and family concerns, recommendations, and changes in care needs are addressed and incorporated into care plans.
• Directs, supervises, and reviews nursing aspects of resident admissions, readmissions, transfers, and discharges, including assessments, documentation, care planning, equipment and supply needs, and continuity of care.
• Serve as the primary contact for residents and families regarding ongoing care coordination, treatment concerns, and care planning. Maintain timely, professional communication and ensure appropriate follow-up on concerns and changes in resident conditions.
• Provide ongoing clinical guidance, education, and support to RNs, LPNs, CNAs, and other nursing staff regarding resident care needs, care plan interventions, documentation, and changes in condition. Identify and communicate recurring care concerns to nursing leadership.
• Assist with direct resident care, nursing duties, medication administration, and charge nurse coverage as needed to support staffing, resident safety, and facility operations. Perform nursing responsibilities consistent with RN licensure, competency, and facility policies.
• Coordinate and participate in scheduled provider rounds for all Care Center residents. Communicate changes in condition, medication effectiveness, and treatment concerns while ensuring timely follow-up on provider orders, referrals, laboratory results, and resident appointments.
• Review resident clinical documentation daily for accuracy, completeness, changes in condition, and outstanding care needs. Ensure timely follow-up, address documentation concerns with nursing staff, and maintain accurate and efficient use of the electronic medical record (EMR).
• Monitor medication effectiveness and psychotropic medication use, including adverse effects, behavioral interventions, and gradual dose reduction when clinically appropriate.
• Complete renewals for the use of psychotropic medications to ensure safe and effective treatment.
• Complete required medication reviews, monthly med check ins, and medication record reconciliation (retypes) as indicated, ensuring accuracy and appropriate follow-up.
• Complete consultant pharmacist recommendations, coordinate provider follow-up, and assist with prior authorization documentation.
• Complete and document antibiotic time-outs as indicated, including review of treatment appropriateness, clinical response, and necessary provider follow-up.
• Collaborate with the interdisciplinary team to identify, assess, monitor, and manage skin concerns, ensuring appropriate interventions, documentation, and care plan updates.
• Collaborates with county agencies, Social Services, and the interdisciplinary team to coordinate resident services and ensure appropriate coverage of care.
• Actively participates in the coordination, administration, documentation, and follow-up of routine, seasonal, and required immunizations in accordance with facility policies and applicable regulations.
• Complete and coordinate medication prior authorization requests as needed, including required clinical documentation and follow-up to prevent interruptions in treatment.
• Participate in the interdisciplinary care center team.
• Actively serves in Quality Assurance and Performance Improvement (QAPI) activities, clinical audits, quality subcommittees, task forces, and corrective action initiatives to improve resident care and outcomes.
• Actively participate in Minnesota Department of Health (MDH) and other regulatory surveys, including preparation, record reviews, investigations, and corrective action follow-up. Ensure nursing practices comply with applicable regulations, infection prevention standards, and facility policies.
• Identify gaps in resident care, monitor the effectiveness of interventions, ensure appropriate follow-up on unresolved clinical concerns, and communicate issues requiring additional intervention to the ADON or DON.
• Promote teamwork, professional accountability, and positive working relationships.
• Support and participate in JMHS events and activities as appropriate.
• Ability to use electronic medical record (EMR) accurately & efficiently.
• Help others succeed.
• Other duties as assigned.

STANDARD REQUIREMENTS

• Supports the Mission, Vision, and Values at Johnson Memorial Health Services.
• Is knowledgeable of resident rights and ensures an atmosphere that allows for the privacy, dignity, and well-being of all residents in a safe, secure environment.
• Supports, cooperates with, and implements specific procedures and programs for:
  • Safety, including universal precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair, and maintenance needs.
  • Confidentiality of all data, including patient, resident, employee, and operations data.
  • Quality assurance and compliance with all regulatory requirements.
  • Compliance with current law and policy to provide a work environment free from any sort of harassment and all illegal and discriminatory behavior.
• Supports and participates in common teamwork:
  • Cooperates and works together with all co-workers; plans and completes job duties with minimal supervisory direction including appropriate judgment.
  • Uses tactful, appropriate communication in sensitive and emotional situations.
  • Follow up as appropriate with supervisors, co-workers, patients or residents regarding reported complaints, problems, and/or concerns.
  • Promotes positive public relations with patients, residents, family members, and guests. Completes requirements for in-service and annual training, acceptable attendance, uniform dress codes including personal hygiene, and other work duties as assigned.

QUALIFICATIONS

• Current, active Registered Nurse (RN) licensure in Minnesota.
• Strong clinical assessment, communication, critical thinking, and organizational skills.
• Ability to prioritize resident care needs, coordinate multiple responsibilities, and work effectively with an interdisciplinary team.
• Ability to use electronic medical records accurately and efficiently.
• Experience with PointClickCare (PCC) and Epic electronic health record (EHR) systems preferred.
• Three or more years of nursing experience in long-term care or skilled nursing preferred.
• Experience with comprehensive resident assessments, care planning, MDS, wound care, and quality improvement preferred.

Benefits Offered for 48+ hours (.6 FTE)

• Medical Insurance
• Dental Insurance
• Vision Insurance
• Life Insurance
• Flexible Spending (FSA)
• Health Savings (HSA)
• Supplemental Insurances
• Retirement (401a/457 Plan) 
• Paid Time Off 
• Employee Sick & Safety Leave
• Extended Illness Bank

The foregoing statements describe the general purpose and responsibilities assigned to this job and are not an exhaustive list of all responsibilities and duties that may be assigned or skills that may be required.

We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

JHMS is committed to the full inclusion of all qualified individuals. As part of this commitment. JHMS will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed, please contact the Human Resources Department.