Patient Care Coordinator RN, Virginia Hospital Center
4 weeks ago
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.
Key Responsibilities:- Conducts initial face-to-face assessments for every admitted member to identify discharge needs within 24 hours of admission.
- Documents assessment outcomes in KPHC and communicates with the MAPMG physician healthcare team and patient/family to determine the appropriate transition plan.
- Participates in daily Care Without Delay (CWD) rounds, reporting on patient progression towards the established discharge plan.
- Reviews and documents discharge plans in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.
- Documents 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 Workers 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.
- Identifies, records, and escalates delays in care and barriers to discharge, providing solutions to correct delays and recognizing systemic patterns that require corrective action.
- Ensures follow-up appointments and referrals to ambulatory case managers for high-risk patient populations are scheduled and communicated to patient/family prior to discharge.
- Observes all facility safety policies and procedures, including infection control, Member Rights policies, and 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.
- Works cooperatively with patients, patient representatives, facility staff, physicians, consultants, and ancillary service providers.
- Minimum of one year of experience in an acute medical/surgical/ED or critical care nursing area.
- Associate Nursing degree required.
- Registered Nurse License (Maryland) within six months of hire and Registered Nurse License (Virginia) within six months of hire.
- Compact License: Registered Nurse within six months of hire.
- Basic Life Support.
- Recent acute care, case management, or home health experience preferred.
- BSN preferred.
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