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Healthcare Coordination Specialist

2 months ago

Glenn Dale, Maryland, United States Kaiser Permanente Full time

Position Overview:
The Healthcare Coordination Specialist plays a pivotal role in managing and orchestrating care for patients in acute inpatient settings.

This role involves collaboration with MAPMG Hospital Based Service Physicians, patients and their families, nursing staff, utilization review teams, and other healthcare professionals to ensure a seamless continuum of care that achieves both clinical and cost-effective outcomes.

The Specialist is responsible for facilitating connections with community providers and ambulatory case managers to ensure safe transitions of care and to minimize the risk of readmission.


Key Responsibilities:
Conduct an initial in-person assessment for each admitted patient to identify discharge requirements within 24 hours of admission.

Record findings in KPHC and communicate assessment results to establish an appropriate transition plan in conjunction with the MAPMG healthcare team and the patient/family.

Actively participate in daily Care Without Delay (CWD) rounds, providing updates on patient progress toward discharge goals.
Review and document discharge plans in accordance with KP policies, facility protocols, and regulatory standards.
Maintain daily documentation of updates, care progress, and any obstacles to discharge for assigned patients.
Coordinate with physicians and nursing staff to ensure timely care progression and prevent unnecessary delays.
Work with Social Workers to arrange long-term care, assisted living, financial support, and other necessary services.

Facilitate referrals and communication with in-network vendors for post-acute care services, including Home Health, DME, IV infusion, SNF, Sub-Acute, and Acute Rehabilitation.

Identify, document, and escalate any delays in care and barriers to discharge promptly. Propose solutions to address delays and recognize systemic issues that require corrective measures.

Ensure follow-up appointments and referrals to ambulatory case managers for high-risk patients are scheduled and communicated to patients and families prior to discharge.

Adhere to all facility safety protocols and procedures, including infection control and patient rights policies.
Engage in Quality Assurance activities and contribute to initiatives aimed at enhancing care quality indicators.
Maintain professionalism in all tasks, executing duties effectively and promptly as directed by the designated supervisor.
Consistently collaborate with patients, their representatives, facility staff, physicians, consultants, and ancillary service providers.

Every other weekend and holiday commitment required.

Qualifications:
Experience
A minimum of one (1) year in an acute medical/surgical/ED or critical care nursing environment.

Education
An Associate Nursing degree is required.

Licensure, Certification, Registration
This position requires credentials from multiple states. Credentials from the primary work state must be obtained before hire. Additional credentials from secondary states are required post-hire.
Registered Nurse License (Maryland) within 6 months of hire AND Registered Nurse License (Virginia) 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 certification.

Additional Requirements:
Experience with electronic medical record systems is essential.
Familiarity with health/care reimbursement systems (Medicare Advantage, Commercial payer, Medicaid, and CMS regulatory rules) is preferred.

Annually:
Successful completion of PCC Assessment of Critical Skills, with a passing score on inter-rater reliability.
Ability to communicate effectively with physicians, members, their families or representatives, and hospital staff.
Capability to work independently while applying critical thinking for problem-solving and decision-making.
Adherence to KP Employees Handbook and facility policies and procedures.
Excellent time management skills to develop organized workflows in a high-volume environment with rapidly changing priorities.
Intermediate proficiency in computer skills (Microsoft Office Suite).
Ability to manage and cope with ambiguity.
Capacity to foster teamwork and work effectively as part of a team.
Outstanding verbal and written communication skills.
Ability to engage and communicate effectively with key internal and external stakeholders.
Deliver exceptional customer service to enhance the patient experience.

Preferred Qualifications:
Recent experience in acute care, case management, or home health is preferred.
A Bachelor of Science in Nursing (BSN) is preferred.
Experience in inpatient discharge planning is preferred.

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