Patient Care Coordinator

Kaiser Permanente - Largo, MD

Full-time

Largo, MD

Ambulatory Health Care Services

About the position

The Patient Care Coordinator (PCC) at Kaiser Permanente is responsible for managing and coordinating care for acute inpatient populations. This role involves collaboration with healthcare teams, including physicians, nursing staff, and social workers, to ensure effective patient care progression, safe discharges, and prevention of readmissions. The PCC plays a critical role in assessing patient needs, documenting care plans, and facilitating communication among various stakeholders to enhance patient outcomes.

Responsibilities

• Complete an initial face-to-face assessment for every admitted member to identify discharge needs within 24 hours of admission.
• Document in KPHC and communicate the assessment outcomes to determine the appropriate transition plan with MAPMG physician healthcare team and patient/family.
• Participate actively in daily Care Without Delay (CWD) rounds reporting 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.
• 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.
• 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.
• 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 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.
• Work cooperatively with patients, patients representatives, facility staff, physicians, consultants, and ancillary service providers.

Requirements

• 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 OR Registered Nurse License (District of Columbia) within 6 months of hire.
• Basic Life Support certification required.
• 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).
• 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.
• 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.

Nice-to-haves

• Recent acute care, case management, or home health experience preferred.
• BSN preferred.