Patient Care Coordinator

Kaiser Permanente-posted 4 months ago
Glen Burnie, MD
Ambulatory Health Care Services
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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.

  • Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24hrs of admission.
  • Document in KPHC and communicate the assessment outcomes to determine the appropriate transition plan with MAPMG physician healthcare team and patient/family.
  • Active participant in daily Care Without Delay (CWD) rounds reporting on patient progression towards the established discharge plan.
  • Review and document discharge plan in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.
  • Document any 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 or days.
  • Collaborate with Social Worker to coordinate, long-term care, assisted living, financial assistance, and other services, as required.
  • Send referrals/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 manager for high-risk patient population are scheduled and communicated to patient/family 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 supervisor.
  • Consistently work cooperatively with patients, patients representatives, facility staff, physicians, consultants, and ancillary service providers.
  • Minimum of one (1) year 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 Registered Nurse License (District of Columbia) 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).
  • Annually: Successful completion of PCC Assessment of Critical Skills, Passing score on inter-rater reliability.
  • Must be able 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.
  • Must have 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 to 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.
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