A Skilled Nursing Facility Care Coordinator manages patient care at admission. The Skilled Nursing Facility Care Coordinator keeps close contact with the Manager of Transitional/PostAcute Teams and the Vice President of Clinical Services throughout the patient’s stay to monitor progression and facilitate PCP and specialty follow up.



a. Initiate direct visit contact within 24-48 hours of admission and introduce all services to patient.
b. Review admission orders and medical records.
c. Send recommended length of stay to health plan within 3 days of admission for continuation of SNF stay authorization.
d. Document visit and findings in progress note through Carepointe portal. 
e. Assist facility CM and SW teams in discharge planning by providing resources available through medical group.
f. Target to get patients back in their home setting, with the highest levels of care available.
g. Provide daily feedback to the VP of Clinical Services and Manager of transitional/Post-Acute Teams on SNF utilization.
h. Identify discharge needs (DME, assisted living, SW, ICM, PCP/specialty follow up.)
i. Ensure proper orders are in place and all additional home services have been arranged (HH, Mobile Physician, and NP) upon discharge.
j. Strive to control health plan costs by reviewing patient’s needs and establishing services in the home.
k. Identify patient needs early and often to aid in the discharge planning process.
l. Establish discharge plan and home-based plan at the time of admission to SNF.
m. Identify appropriate USHS clinical service program for patient following discharge (TCM/ICM/PC/NP)
n. Collect concurrent review date and deliver to health plan.
o. Complete other duties as assigned.



a. Know and follow Employee Handbook policies and procedures.
b. Communicate verbally and in writing through proper channels.
c. Maintain patient confidentiality. Be HIPAA compliant by observing HIPAA and group’s guidelines.
d. Use time clock appropriately.
e. Participate in staff meetings.
f. Follow dress code.
g. Notify supervisor in writing when requesting paid time off.
h. Be courteous.
i. Be flexible and adaptable.
j. Promote departmental and organizational goals.
k. Know and follow applicable safety standards.



a. Work Position:

i. Sitting – 10%
ii. Standing – 20%
iii. Walking – 70%

b. Body Movements:

i. Lifting 0-20-pounds; books, reams of paper, files, etc.- 10%
ii. Bending, stooping and squatting- 10%
iii. Reaching above head to 75 degrees less than- 10%
iv. Grip/hand dexterity; writing – 60%
v. Climbing stairs- 10%



a. Language & Communication Skills:

i. Must be able to understand and communicate in English language.
ii. Must be able to communicate effectively with patients, families, health plan, and all providers.
iii. Communicate and understand features of Medicare, Medicaid, and other contracted insurance providers.

b. Decision Making:

i. Ability to make clinical decisions for routine patient care and critically think to assist patient with complex medical issues.

c. Computer Skills:

i. Must have basic computer skills, including use of Microsoft Word and Office.
ii. Must master use of Care Pointe care management proprietary software.

d. Problem Solving:

i. Must be able to multitask and handle numerous responsibilities throughout each day and make clinical decisions regarding routine and complex patient care.



a. Must have current, unencumbered Registered Nurse or Licensed Practical Nursing License and graduated from an accredited Nursing program.
b. Current BLS/CPR certification required.
c. Current TB test and maintain a negative test annually required.
d. Arizona Fingerprint Clearance Card required.
e. Hep B vax/titer proof (Company does offer/or may sign a declination) required.
f. Current flu shot (or sign waiver/follow mask policy) required.
g. Having an in-depth knowledge of health care services and other medical terminology is a required.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned, and management retains the right to add or change the duties at any time. The above expectations have been explained and discussed with me. I understand that my performance will be evaluated based upon these expectations.

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