Patient Care Coordinator

Job Summary

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 continuity 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 prevention of re‑admission.

• Completes an initial face‑to‑face assessment for every admitted member to identify discharge needs within 24 hours of admission.
• Documents in KPHC and communicates the assessment outcomes to determine the appropriate transition plan with the MAPMG physician healthcare team and patient/family.
• Active participant in daily Care Without Delay (CWD) rounds reporting on patient progression toward 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 days.
• Collaborates with Social Worker to coordinate long‑term care, assisted living, financial assistance, and other services, as required.
• Sends referrals and 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, patient 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.

• Credentials from multiple states. Credentials from the primary work state are required itional credentials from 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.
• 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).
• Annual completion of PCC Assessment of Critical Skills with passing score on inter‑rater reliability.
• Effective communication 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.
• Adherence to KP Employees Handbook and facility policies and procedures.
• Excellently timed management skills for organizing 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 work effectively as a team member.
• Excellent verbal and written communication skills.
• Effecti…