Patient Care Coordinator
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, utilization 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.
Essential responsibilities include:
- Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24hrs of admission.
- Documents in KPHC and communicates 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.
- Reviews and documents discharge plan in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.
- Documents any updates, care progression and barriers to discharge daily, and as indicated on assigned patients.
- Manages timeliness of care progression with physician and nursing staff to prevent avoidable delays and or days.
- Collaborates with Social Worker to coordinate, long-term care, assisted living, financial assistance, and other services, as required.
- Sends referrals/communicates 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. Provides solutions to correct delays and recognizes systemic patterns that require corrective action.
- Assures follow up appointments and referrals to ambulatory case manager for high-risk patient population are scheduled and communicated to patient/family prior to discharge.
- Observes all facility safety policies and procedures (infection control, Members Rights policies, and any regulatory requirements)
- Participates in Quality Assurance duties and implementation of programs to improve care Quality Indicators.
- Maintains professionalism with all duties in an effective and timely manner as directed or assigned by designated supervisor.
- Consistently works cooperatively with patients, patients representatives, facility staff, physicians, consultants, and ancillary service providers.
Basic qualifications include:
- Minimum of one (1) year in an acute medical/surgical/ED or critical care nursing area.
- Associate Nursing degree required.
- 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 AND Registered Nurse License (District of Columbia) within 6 months of hire.
- Basic Life Support
Additional requirements include:
- 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 excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
- Intermediate computer skills (Microsoft Office Suite proficiency).
- Ability to tolerate and cope with ambiguity.
- Ability to promote 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 stakeholders.
- Provide excellent customer service to promote excellence in the patient experience.
Preferred qualifications include:
- Recent acute care, case management, or home health experience preferred.
- BSN preferred.