The Patient Care Coordinator is responsible for overseeing the management and coordination of care for the acute inpatient population. The PCC collaborates with rounding MAPMG Hospital Based Service Physicians, patient/family, nursing, utlization review and other members of the healthcare team to assure continuum of patient care progression for clinical and cost-effective outcomes. The PCC facilitates and coordinates with community providers and ambulatory case managers to assist with the appropriate level and transition of care for a safe discharge and preventing a re-admission.

• Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24hrs of admission.


• Document in KPHC and communicate the assessment outcomes to determine the appropriate transition plan with MAPMG physician healthcare team and patient/family.


• Active participant in daily Care Without Delay (CWD) rounds reporting on patient progression towards the established discharge plan.


• Review and document discharge plan in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.


• Document any updates, care progression and barriers to discharge daily, and as indicated on assigned patients.


• Manage timeliness of care progression with physician and nursing staff to prevent avoidable delays and or days.


• Collaborate with Social Worker to coordinate, long-term care, assisted living, financial assistance, and other services, as required.


• Send referrals/communicate with in-network vendors for coordination of post-acute levels of care such as Home Health, DME, IV infusion, SNF, Sub-Acute and Acute Rehab.


• Timely identification, recording, and escalation of delays in care and barriers to discharge. Provide solutions to correct delays and recognize systemic patterns that require corrective action.


• Assure follow up appointments and referrals to ambulatory case manager for high-risk patient population are scheduled and communicated to patient/family prior to discharge.


• Observe all facility safety policies and procedures (infection control, Members Rights policies, and any regulatory requirements)


• Participate in Quality Assurance duties and implementation of programs to improve care Quality Indicators.


• Maintain professionalism with all duties in an effective and timely manner as directed or assigned by designated supervisor.


• Consistently work cooperatively with patients, patients representatives, facility staff, physicians, consultants, and ancillary service providers.

• Minimum of one (1) year in an acute medical/surgical/ED or critical care nursing area.

• Associate Nursing degree required.

• This job requires credentials from multiple states. Credentials from the primary work state are required at hire. Additional Credentials from the secondary work state(s) are required post hire.
  

• Registered Nurse License (Virginia) within 6 months of hire AND Registered Nurse License (Maryland) within 6 months of hire

OR

• Compact License: Registered Nurse within 6 months of hire

• Registered Nurse License (District of Columbia) within 6 months of hire
  

• Basic Life Support
  

• Experience using an electronic medical record system
• Some awareness or knowledge of health/care reimbursement systems (Medicare Advantage, Commercial payer, Medicaid and CMS regulatory rules)
• Annually: Successful completion of PCC Assessment of Critical Skills, Passing score on inter-rater reliability.
• Must be able to effectively communicate with physicians, members and their family or representatives, and hospital staff.
• Ability to work independently and apply critical thinking skills for problem solving and decision making.
• Adheres to KP Employees Handbook and facility policies and procedures.
• Must have excllent time management skills to develop organized work processess in a high-volume envirornment with rapidly changing priorities.
• Intermediate computer skills (Microsoft Office Suite proficiency).
• Ability to tolerate and cope with ambiguity.
• Ability to pormote teamwork and to work effectively as a team member.
• Excellent verbal and written communication skills.
• Ability to interact/communicate effectively with key internal and external stake holders.
• Provide excellent customer service to promote excellence in the patient experience.

• Recent acute care, case management, or home health experience preferred.
• BSN preferred.

Notes:

• Inpatient Discharge Planning experience preferred