Patient Care Coordinator RN

3 weeks ago


Arlington, Virginia, 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. This role collaborates with the healthcare team to ensure a continuum of patient care progression for clinical and cost-effective outcomes.

Key Responsibilities:
  • Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24 hours of admission.
  • Documents assessment outcomes and communicates with the healthcare team to determine the appropriate transition plan.
  • Participates in daily Care Without Delay (CWD) rounds to report 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.
  • Collaborates with Social Workers to coordinate long-term care, assisted living, financial assistance, and other services as required.
  • Coordinates referrals with in-network vendors for 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 patients and families prior to discharge.
Requirements:
  • 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 6 months of hire, and Registered Nurse License (Virginia) within 6 months of hire, or Compact License: Registered Nurse within 6 months of hire.
  • Basic Life Support certification.
  • 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).


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