Resident Care Coordinator- Baldwin City.

About the role

• Resident Care Coordinator- The Resident Care Coordinator serves as the primary clinical leader for the assigned Sunflower Care Homes location. This position is responsible for overseeing resident care, coordinating medical services, maintaining clinical systems and documentation, and leading the nursing/caregiving team to ensure residents receive safe, compassionate, individualized care.

What you'll do

POSITION & ON-CALL EXPECTATIONS

• This is a full-time position and requires flexibility based on resident, clinical, and staffing needs.

• Maintain regular presence within the home and remain actively involved in day-to-day resident care and operations.

• Work collaboratively with the DOH/AED/ED to ensure appropriate nursing coverage and continuity of care.

• Participate in the established nursing on-call rotation.

• Provide after-hours nursing support and clinical guidance to staff when on call.

• Respond promptly to calls regarding changes in resident condition, falls, medication concerns, behaviors, injuries, illness, or other clinical situations.

• Determine when a resident requires additional nursing assessment, provider notification, emergency evaluation, or transfer to a higher level of care.

• Be available to come into the home when a resident situation cannot be safely or appropriately managed by telephone.

• Ensure significant after-hours clinical events are appropriately documented and communicated to the DOH/AED/ED/.

• Follow through on issues occurring while on call to ensure appropriate resolution and next-day follow-up.

• Participate in the established staffing on-call rotation.

• Respond to staffing call-ins and unexpected staffing shortages when assigned staffing on-call.

• Assist with finding appropriate coverage for open shifts and call-ins.

• Communicate staffing concerns and unresolved coverage needs to the DOH/ED/AED.

• When appropriate coverage cannot be secured, assist in ensuring the home remains safely staffed, which may include working or providing direct resident care when necessary.

• Maintain professional and timely communication with staff while serving in either nursing or staffing on-call capacity.

• Understand that leadership responsibility extends beyond scheduled office hours when resident safety, nursing needs, or safe staffing require intervention.

RESIDENT CARE MANAGEMENT & OVERSIGHT

• Manage and provide ongoing clinical oversight of resident care.

• Maintain a working knowledge of each resident's diagnoses, baseline condition, current needs, medications, behaviors, risks, and plan of care.

• Routinely assess residents and identify changes in physical, cognitive, behavioral, or emotional condition.

• Ensure changes in condition are appropriately assessed, documented, communicated, and followed through to resolution.

• Review resident charts routinely for new concerns, trends, or incomplete follow-up.

• Monitor residents following falls, illness, infections, medication changes, ER visits, hospitalizations, or other significant events.

• Ensure physician orders and treatment recommendations are implemented promptly.

• Ensure resident preferences, dignity, independence, and quality of life remain central to care decisions.

• Provide clinical guidance to staff regarding resident-specific care needs.

• Identify residents requiring increased monitoring and establish appropriate follow-up.

• Serve as the primary nursing resource during state surveys. 

PHYSICIAN APPOINTMENTS & MEDICAL CARE COORDINATION

• Manage and coordinate resident physician and specialty appointments.

• Ensure appointments are scheduled and necessary paperwork/information accompanies the resident.

• Prepare pertinent clinical information and questions prior to appointments.

• Review appointment documentation and recommendations upon the resident's return.

• Obtain and implement new physician orders.

• Communicate appointment outcomes and significant changes to appropriate staff and family/DPOA.

• Maintain appropriate documentation of upcoming and completed appointments.

• Participate in physician rounding within the home.

• Prepare residents and records for provider rounds.

• Round with providers and communicate current resident concerns.

• Ensure all orders and recommendations resulting from rounds are completed and documented.

• Follow up with provider offices when orders, records, referrals, or recommendations remain outstanding.

ENCOUNTER TELEHEALTH SERVICES

• Coordinate and manage Encounter Telehealth services for residents.

• Schedule and facilitate psychiatric/mental-health telehealth appointments.

• Coordinate resident talk-therapy appointments.

• Ensure residents are prepared and available for scheduled visits.

• Provide Encounter clinicians with relevant resident information and behavioral observations when appropriate.

• Review recommendations and new orders following Encounter visits.

• Ensure medication or treatment changes are implemented.

• Communicate significant recommendations to staff, families/DPOAs, pharmacy, and other providers as appropriate.

• Monitor resident response to psychiatric medication changes and behavioral interventions.

• Maintain Encounter documentation within the resident record.

MEDICATION PROGRAM MANAGEMENT

• Manage and maintain the SCH medication management program.

• Ensure the medication program remains compliant with applicable Home Plus regulations. 

• Routinely audit Medication Administration Records (MARs).

• Review medication records for omissions, discrepancies, missed signatures, discontinued medications, or other concerns.

• Ensure new medication orders are entered and implemented accurately and timely.

• Verify discontinued medications are appropriately removed from active medication administration.

• Monitor PRN medication use and effectiveness.

• Monitor residents for medication side effects, adverse reactions, and changes following medication adjustments.

• Coordinate medication refills and communicate with pharmacies and providers as necessary.

• Maintain appropriate medication storage and medication-room organization.

• Monitor controlled medications and required documentation.

• Investigate medication errors and ensure appropriate documentation, notification, follow-up, and staff education.

• Complete and/or oversee routine medication audits.

• Manage and follow up on POS medication reviews.

• Review and address recommendations from pharmacy consultant reviews.

• Ensure pharmacy recommendations are communicated to providers and resolved appropriately.

• Train, educate, and check off CMAs regarding medication administration expectations and identified concerns.

SKIN INTEGRITY & WOUND MANAGEMENT

• Ensure routine skin assessments are completed and documented.

• Monitor residents for skin tears, bruising, pressure areas, rashes, redness, breakdown, and wounds.

• Ensure new skin concerns are documented and communicated promptly.

• Coordinate wound care orders and outside wound-care services when needed.

• Monitor wound measurements, treatment, progression, and healing.

• Ensure ordered treatments are completed and properly documented.

• Communicate significant skin or wound changes to providers and families/DPOAs.

• Identify residents at increased risk for skin breakdown and implement preventative interventions.

• Review documentation for patterns of repeated skin concerns.

• Monitor and address resident bathing/showering refusals.

• Ensure repeated refusals are documented, communicated, and appropriately addressed.

• Work with staff to develop individualized approaches for residents who routinely refuse bathing or personal care.

BOWEL MONITORING

• Manage and oversee resident bowel monitoring.

• Ensure staff accurately document bowel movements.

• Routinely review bowel records for residents at risk for constipation or impaction.

• Identify residents who have gone an abnormal length of time without a documented bowel movement.

• Ensure appropriate PRN interventions and physician orders are followed.

• Monitor effectiveness of bowel interventions.

• Notify providers when interventions are ineffective or additional orders are needed.

• Monitor residents receiving medications that increase constipation risk.

• Educate staff on the importance of accurate bowel documentation and timely reporting.

OUTSIDE SERVICE PROVIDERS

• Manage and maintain relationships with outside healthcare service providers.

• Coordinate services including hospice, home health, therapies, laboratory, mobile imaging, podiatry, and other outside providers as applicable.

• Ensure outside providers have necessary resident information and current orders.

• Maintain current orders and documentation for outside services.

• Obtain and review provider visit notes.

• Ensure outside service notes are filed/uploaded within the resident's clinical record.

• Review recommendations and ensure appropriate follow-up.

• Communicate changes or recommendations to staff, families/DPOAs, physicians, and administration as appropriate.

• Monitor whether ordered services are actually occurring as scheduled.

• Follow up promptly when services, notes, orders, or communication are missing.

FUNCTIONAL CAPACITY SCREENS (FCS)

• Maintain current Functional Capacity Screens for all residents as required.

• Complete/update FCS documentation following significant changes in resident condition when appropriate.

• Ensure the FCS accurately reflects the resident's current functional abilities and care needs.

• Monitor due dates and prevent assessments from becoming overdue.

• Communicate changes identified through assessment to the care team.

NEGOTIATED SERVICE AGREEMENTS / CARE PLANS

• Develop, review, and maintain current Negotiated Service Agreements/Care Plans.

• Ensure each resident's care plan accurately reflects their current needs, preferences, risks, and required assistance.

• Update plans following significant changes in condition.

• Update plans following hospitalizations, rehabilitation stays, falls, behavioral changes, functional decline, or other major changes when indicated.

• Ensure staff understand resident-specific care-plan expectations.

• Communicate significant changes with residents and/or responsible parties.

• Obtain required signatures and maintain completed documentation.

• Routinely compare actual resident care needs with the documented plan to ensure consistency.

NEW ADMISSIONS

• Assist the DOH/ED with clinical review and admission of new residents.

• Review medical records and clinical information prior to admission.

• Assist in determining whether SCH can safely and appropriately meet the prospective resident's needs.

• Obtain and review current medication lists and physician orders.

• Coordinate medications with the pharmacy prior to or immediately following admission.

• Ensure necessary medical equipment, supplies, and outside services are arranged.

• Complete required nursing assessments and admission documentation.

• Establish the initial resident care plan/Negotiated Service Agreement.

• Communicate new resident needs and expectations to the care team.

• Closely monitor new residents during the transition period.

• Maintain communication with the family/DPOA during the admission process.

HOSPITAL & REHABILITATION RETURNS

• Coordinate resident return following hospitalization, ER visit, or rehabilitation stay.

• Obtain and review discharge paperwork prior to or immediately upon return.

• Complete medication reconciliation.

• Identify new, changed, and discontinued medications.

• Ensure new physician orders are implemented.

• Arrange new equipment, therapy, home health, hospice, wound care, or other services as ordered.

• Assess the resident for changes from their previous baseline.

• Update the FCS and Negotiated Service Agreement/Care Plan when indicated.

• Educate staff regarding new care needs and precautions.

• Communicate significant changes with family/DPOA.

• Closely monitor the resident during the post-hospital transition.

INCIDENT REPORTING & CLINICAL CHARTING

• Manage and maintain the incident-reporting process.

• Ensure incidents are documented accurately, objectively, and timely.

• Review incident reports for completeness.

• Ensure appropriate nursing assessment and follow-up occur after incidents.

• Complete required provider and family/DPOA notifications.

• Ensure appropriate monitoring is initiated following falls or other incidents.

• Follow incidents through resolution rather than considering the report itself the completion of the process.

• Identify repeated incidents and clinical trends.

• Following Root Cause Analysis (RCA) develop or recommend interventions to reduce recurrence.

• Ensure appropriate charting is completed regarding resident condition and follow-up.

• Communicate serious or unusual incidents immediately to the DOH/AED/ED.

• Assist with required reporting to KDADS when needed. 

FAMILY COMMUNICATION & RELATIONSHIPS

• Maintain professional, compassionate, and consistent relationships with resident families and DPOAs.

• Serve as a primary clinical resource for families regarding resident care.

• Communicate significant changes in condition promptly.

• Keep families informed following falls, illnesses, medication changes, hospitalizations, provider visits, or other significant clinical events as appropriate.

• Listen to family concerns and respond professionally.

• Follow through on questions or concerns rather than allowing communication to go unanswered.

• Maintain appropriate professional boundaries while building trusting relationships.

• Communicate difficult information with compassion, clarity, and honesty.

• Escalate significant family concerns or conflicts to the DOH/AED/ED.

• Work collaboratively with families while keeping the resident's safety, dignity, wishes, and best interests at the center of care.

NURSING TEAM LEADERSHIP & TRAINING

• Serve as the clinical leader for CNAs, CMAs, fellow nurses. 

• Provide staff with clear expectations regarding resident care.

• Be available as a clinical resource for appropriate nursing questions and resident concerns.

• Train new staff regarding resident-specific clinical needs.

• Participate in orientation and ongoing staff education.

• Provide medication-related training and education to CMAs.

• Train staff on appropriate documentation and reporting expectations.

• Educate staff regarding skin monitoring, bowel monitoring, falls, infection control, behaviors, and changes in condition.

• Reinforce when staff must immediately notify the nurse.

• Identify staff knowledge or competency concerns and provide additional education.

• Hold staff accountable for following resident care plans and nursing direction.

• Address unsafe practices immediately.

• Coach staff respectfully when improvement is needed.

• Communicate ongoing performance concerns to the DOH/AED/ED.

• Promote effective communication between shifts.

• Encourage staff to report concerns early rather than waiting for a problem to become an emergency.

• Model professionalism, dependability, teamwork, compassion, and accountability.

• Lead by example and assist with direct resident care when necessary.

• Help create a nursing team that takes ownership of resident care rather than simply completing assigned tasks.

OVERALL TEAM LEAD NURSE EXPECTATION

The Resident Care Coordinator is expected to manage, lead, communicate, and follow through. The role is not simply to identify a clinical concern or pass information along. The Team Lead Nurse maintains ownership of clinical issues until the appropriate assessment, communication, orders, interventions, documentation, and follow-up have been completed.

The Resident Care Coordinator works closely with the DOH/AED/ED while serving as the day-to-day clinical leader of the home. They are expected to protect resident safety while preserving the comfortable, personal, home-like environment that defines Sunflower Care Homes.

Above all, the Resident Care Coordinator is expected to demonstrate the Sunflower Care Homes values of dignity, compassion, kindness, patience, respect, teamwork, and accountability.

Qualifications

• Valid Kansas Nursing License

About Sunflower Care Homes

We take pride in providing quality care with a personal touch to our residents. We are a licensed Homeplus with a max of 16 residents, specializing in memory care. Our small, comfortable, home setting is appealing to most. Come work with us where you can make a difference!

We hire the heart and train the mind. Experience is appreciated but we will hire a new caregivers if you have a niche and LOVE for caregiving.