RN, Care Coordinator - Librus

It’s inspiring to work with a company where people truly BELIEVE in what they’re doing!

When you become part of the Chapters Health Team, you’ll realize it’s more than a job. It’s a mission. We’re committed to providing outstanding patient care and a high level of customer service in our communities every day. Our employees make all the difference in our success!

Role: The Librus RN Care Coordinator is critical in delivering proactive, person-centered care to members enrolled in an Institutional Special Needs Plan (ISNP) or ACO through multiple payors. Embedded in contracted Skilled Nursing Facilities (SNFs), this position is responsible for care coordination, clinical assessments, and ongoing case management of high-acuity, high-complexity patients. This RN is a clinical integrator across interdisciplinary teams, ensuring care aligns with the payor's Model of Care. They also support members and families through advanced illness trajectories by providing comfort, dignity, and goal-concordant care services.

Required Qualifications:

• Required RN License
• Certification of completion of Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs.
• Experience managing interdisciplinary teams
• Familiarity with ISNP metrics and reporting
• Skilled in workflow optimization and staff supervision

Preferred Qualifications:

• Minimum of 3 years of clinical experience in long-term care, hospice, or geriatric case management.
• Certification in Case Management (CCM) or related field.
• Palliative care or hospice experience (formal or informal).
• Familiarity with CMS ISNP regulatory guidelines and quality metrics.

Competencies:

• Satisfactorily complete competency requirements for this position.
• Clinical judgment and triage excellence
• Relationship-building across disciplines and settings
• Strong communication skills, including sensitive conversations
• Cultural competence and compassion for vulnerable populations
• Proactive, detail-oriented, and mission-driven

Responsibilities of all employees:

• Represent the Company professionally at all times through care delivered and/or services provided to all clients.
• Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
• Comply with Company policies, procedures and standard practices.
• Observe the Company's health, safety and security practices.
• Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
• Use resources in a fiscally responsible manner.
• Promote the Company through participation in community and professional organizations.
• Participate proactively in improving performance at the organizational, departmental and individual levels.
• Improve own professional knowledge and skill level.
• Advance electronic media skills.
• Support Company research and educational activities.
• Share expertise with co-workers both formally and informally.
• Participate in Quality Assessment and Performance Improvement activities as appropriate for the position.

Job Responsibilities:

Primary:
• Oversee compliance with HRA, care plan, visit, and ICT cadences
• Track and report on ISNP-aligned metrics and clinical milestones
• Supervise field staff and resolve coordination issues
• Act as liaison to providers, facilities, and ISNP partners

Model of Care Alignment:

• Serve as the clinical steward of the contracted Model of Care within assigned SNFs, ALFs or home environments.
• Ensure all care delivery reflects ISNP or equivalent principles, including person-centeredness, chronic disease management, reduction in avoidable hospitalizations, and proactive goals-of-care discussions.
• Facilitate collaboration between SNF staff, PCPs, Payor clinical teams, and ancillary providers to ensure integrated service delivery.

Care Coordination & Case Management:

• Conduct comprehensive assessments of new members upon admission and re-evaluate with any significant change in condition.
• Develop, implement, and continuously update individualized care plans with SNF IDT or equivalent, facility staff, and families.
• Coordinate services across the care continuum, including specialty consults, mobile urgent care, behavioral health, and palliative approaches as needed.
• Monitor clinical outcomes, intervene in real time to address deterioration, and escalate cases requiring higher-level support.

Advanced Illness Support:

• Provide empathetic, high needs clinical care focused on comfort, dignity, and symptom relief as dictated in the Members Plan of Care.
• Initiate and guide advance care planning conversations and goals-of-care documentation (e.g., POLST, DNR, MOLST).
• Support families through end-of-life processes, offering education, psychosocial support, and appropriate referrals as needed.

Compensation Pay Range:

$60,058.27 - $90,087.92

This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.