Advance Health

Care Coordinator RN - Tidewater

9 months ago(5/3/2017 9:27 AM)
Job ID
Projected Start Date


Advance Health is focused on improving the quality of life for health plan members through health assessments, effective care coordination and best in class care management. The Advance Health Care Management Program is for health plan members residing in their own home, long-term care, residential care, or other facilities.

Advance Health is seeking registered nurses and licensed practical nurses with expertise managing complex populations, experience working in multidisciplinary teams, and the desire to make a difference in people’s lives. While there are many goals of this program, the overriding one is to improve the member’s quality of life and health outcomes.

The Care Coordinator is regionally/locally based and effectively communicates and engages with the members on an ongoing basis to ensure ongoing care coordination services are identified and met using an individualized approach.


  • Conducts initial comprehensive assessments and reassessments as needed within prescribed timeframes on members.
  • Provides effective ongoing care coordination/management of an assigned caseload by routinely evaluating and monitoring status, needs and progress. Adjusting plan of care by changing or adding services including facilitation of referrals as needed to achieve desired outcomes and goals.
  • Develops individualized plans of care in coordination/collaboration with member, family/caregiver, PCP, and other participants of the Interdisciplinary Care Team (ICT). Provides education so that timely and informed decisions can be made.
  • Monitors the provision of services as outlined in the ICP and achievement of desired outcomes.
  • Serves as the primary point of contact for members and the Interdisciplinary Care Team (ICT); Leads ICT process and meetings; facilitates communications among relevant stakeholders.
  • Provides communication and education regarding available services and community resources in a culturally sensitive and developmentally appropriate manner that takes into account the member’s physical and cognitive abilities and level of literacy; assists member in developing self-management skills to effectively access and use services.
  • Actively manages members during care transitions for optimal outcomes.
  • Empowers members to become active participants in their coordinated health care plans.
  • Coordination with community resources and other health services team members as needed to optimize member health outcomes by identifying and overcoming barriers that may impact a member’s compliance to care plan.
  • Identifies and appropriately escalates quality of care issues through prescribed
  • Ongoing monitoring, evaluation, and documentation of care in compliance with company policies and procedures.
  • Performs other care management duties as needed.


  • Current Licensed Practical Nurse or Current Registered Nurse with unrestricted license to practice in the Commonwealth of Virginia.
  • Certified Care Manager preferred.
  • Home Care or Long-Term Care experience preferred.
  • Experience in utilization review, concurrent review and/or risk management a plus.
  • Bi or multilingual ability a plus.
  • Minimum 2 years clinical experience working with complex adult and pediatric populations.
  • Understands and is able to apply principals of Care Management and individualized care planning.
  • Understands and adapts appropriately to issues related to communication, cognitive or other barriers.
  • Strong communication skills and ability to lead an interdisciplinary care team.
  • Strong critical thinking skills.
  • Strong organizational skills and the ability to prioritize and follow through on multiple projects in a timely manner.
  • Comfortable with conducting home visits and commuting using own vehicle (mileage is reimbursed) within the service area up to 10%-20% of the time and on occasion, (if outside the service area) to the home office for meetings and training opportunities; Valid driver’s license and proof of insurance required.
  • PC literate with working knowledge of Microsoft Office and various computer software programs.
  • In-person and remote positions available.



*Advance Health is an Equal Opportunity Employer*



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