Senior Clinical Transition Coordinator

4 days ago

Arlington, Virginia, United States Kaiser Permanente Full time
Patient Care Coordinator RN, Virginia Hospital Center

Job Summary: The Senior Clinical Transition Coordinator is responsible for overseeing the management and coordination of care for the acute inpatient population at Kaiser Permanente's Virginia Hospital Center. Collaborating with rounding physicians, patients/families, nursing staff, utilization review, and other healthcare professionals ensures continuum of patient care progression for clinical and cost-effective outcomes. The coordinator facilitates and coordinates with community providers and ambulatory case managers to assist with the appropriate level and transition of care for safe discharge and preventing re-admission.

Essential Responsibilities:
* Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24 hours of admission, documenting findings in KP HealthConnect and communicating outcomes to determine the transition plan with the MAPMG physician team and patient/family.
* Active participant in daily Care Without Delay (CWD) rounds reporting on patient progress toward established discharge plans, reviewing and documenting 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 for assigned patients, managing timeliness of care progression with physician and nursing staff to prevent avoidable delays and extended hospital stays.
* Collaborates with Social Workers to coordinate long-term care, assisted living, financial assistance, and other services as required, sending referrals/communicating 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, providing solutions to correct delays and recognizing systemic patterns that require corrective action.
* Ensures follow-up appointments and referrals to ambulatory case managers are scheduled and communicated to patients/families prior to discharge, adhering to all facility safety policies and procedures, including infection control, Member Rights policies, and regulatory requirements.
* Participates in Quality Assurance duties and implementation of programs to improve care Quality Indicators, maintaining professionalism with all duties in an effective and timely manner as directed or assigned by designated supervisors.
* Consistently works cooperatively with patients, patient representatives, facility staff, physicians, consultants, and ancillary service providers, utilizing strong communication and interpersonal skills to achieve positive patient outcomes.

Salary: $85,000 - $115,000 per year

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