Patient Care Coordinator

6 days ago

Upper Marlboro, Maryland, 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 requires collaboration with the healthcare team to ensure a continuum of patient care progression for clinical and cost-effective outcomes.

Essential Responsibilities:
  • Conduct initial face-to-face assessments for admitted patients to identify discharge needs within 24 hours of admission.
  • Document assessment outcomes and communicate with the healthcare team 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.
  • Manage timeliness of care progression with physician and nursing staff to prevent avoidable delays and days.
  • 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.
  • Timely identification, recording, and escalation of delays in care and barriers to discharge. Provide solutions to correct delays and recognize systemic patterns that require corrective action.
  • Assure 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.
  • Observe all facility safety policies and procedures (infection control, Members Rights policies, and any 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 or assigned by designated supervisors.
  • Consistently work cooperatively with patients, patient representatives, facility staff, physicians, consultants, and ancillary service providers.
Work Schedule:

Week 1: Monday, Tuesday, Wednesday, Friday, Saturday; Week 2: Sunday, Monday, Tuesday, Thursday, Friday

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 AND Registered Nurse License (District of Columbia) within 6 months of hire.
  • Basic Life Support.
Preferred Qualifications:
  • Recent acute care, case management, or home health experience preferred.
  • BSN preferred.

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