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Patient Care Coordinator
2 months ago
The Patient Care Coordinator is a key member of the healthcare team responsible for overseeing the management and coordination of care for the acute inpatient population at Kaiser Permanente. This role requires collaboration with physicians, nursing staff, and other healthcare professionals to ensure a continuum of patient care progression for clinical and cost-effective outcomes.
Essential Responsibilities:- Conduct initial face-to-face assessments for all admitted patients to identify discharge needs within 24 hours of admission.
- Document assessment outcomes in the electronic medical record 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 Kaiser Permanente's discharge planning documentation policies, facility policies, and regulatory requirements.
- Document updates, care progression, and barriers to discharge daily, and as indicated on assigned patients.
- Manage timeliness of care progression with physician and nursing staff to prevent avoidable delays and readmissions.
- Collaborate with Social Workers to coordinate long-term care, assisted living, financial assistance, and other services as required.
- Refer patients to in-network vendors for 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 patients and 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 implement programs to improve care Quality Indicators.
- Maintain professionalism with all duties in an effective and timely manner as directed or assigned by designated supervisors.
- Work cooperatively with patients, patient representatives, facility staff, physicians, consultants, and ancillary service providers.
- Experience: Minimum of one (1) year in an acute medical/surgical/ED or critical care nursing area.
- Education: Associate Nursing degree required.
- License, Certification, Registration: This role requires credentials from multiple states. Credentials from the primary work state are required before hire. Additional Credentials from the secondary work state(s) are required post-hire.
- 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.
- Basic Life Support.
- 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.
- Recent acute care, case management, or home health experience preferred.
- BSN preferred.
