Patient Care Coordinator

4 days ago

Largo, Florida, United States Kaiser Permanente Full time
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 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:
  • Conduct initial face-to-face assessments for every admitted member to identify discharge needs within 24 hours of admission.
  • Document 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 to report 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.
  • Document updates, care progression, and barriers to discharge daily and as indicated on assigned patients.
  • 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 coordination of post-acute levels of care such as Home Health, DME, IV infusion, SNF, Sub-Acute, and Acute Rehab.
  • Identify, record, and escalate delays in care and barriers to discharge, providing solutions to correct delays and recognizing systemic patterns that require corrective action.
  • Ensure follow-up appointments and referrals to ambulatory case managers for high-risk patient populations are scheduled and communicated to patient/family prior to discharge.
  • Observe all facility safety policies and procedures, including infection control, Member Rights policies, and regulatory requirements.
  • Participate in Quality Assurance duties and implement programs to improve care Quality Indicators.
  • Maintain professionalism with all duties in an effective and timely manner as directed or assigned by designated supervisor.
  • Work cooperatively with patients, patient representatives, facility staff, physicians, consultants, and ancillary service providers.
Work Schedule:
Week 1: M, Tu, W, F, Sa; Week 2: Su, M, Tu, Th, F
Advanced Urgent Care

Requirements:
  • Experience: Minimum of one year in an acute medical/surgical/ED or critical care nursing area.
  • Education: Associate Nursing degree required.
  • License, Certification, Registration: 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 OR Registered Nurse License (District of Columbia) within 6 months of hire.

Additional Requirements:

  • 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.
  • Ability 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.
  • 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 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:
  • Recent acute care, case management, or home health experience preferred.
  • BSN preferred.

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