Clinical Care Navigator
1 week ago
Estimated Salary: $85,000 - $110,000 per year.
Job Summary:
The Patient Care Coordinator RN plays a vital role in overseeing the management and coordination of care for the acute inpatient population at Kaiser Permanente's Virginia Hospital Center. This position collaborates with rounding physicians, patients, families, nursing staff, utilization review, and other healthcare team members to ensure continuum of patient care progression for clinical and cost-effective outcomes.
Key Responsibilities:
- Complete an initial face-to-face assessment for every admitted member within 24 hours of admission to identify discharge needs.
- Document the assessment outcomes in KPHC and communicate with the MAPMG physician healthcare team and patient/family to determine the appropriate transition plan.
- Participate in daily Care Without Delay (CWD) rounds, reporting on patient progression towards the established discharge plan.
- Review and document discharge plans in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.
- Manage timeliness of care progression with physician and nursing staff to prevent avoidable delays or extended hospital stays.
- Collaborate with Social Workers to coordinate long-term care, assisted living, financial assistance, and other services as required.
- Send referrals and communicate with in-network vendors for 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 requiring corrective action.
- Ensure follow-up appointments and referrals to ambulatory case managers for high-risk patient populations are scheduled and communicated to patients/families prior to discharge.
- Adhere to all facility safety policies and procedures, including infection control, Member Rights policies, and 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 by designated supervisors.
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