Description: 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, utlization 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.

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• 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.

Every other Saturday and Sunday

This position will be working out of Sinai Hospital.

Holiday requirement.

Basic Qualifications:

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 job 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

• Registered Nurse License (District of Columbia) within 6 months of hire

• Basic Life Support
  

Additional Requirements:

• 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 stake holders.


• Provide excellent customer service to promote excellence in the patient experience.
  

Preferred Qualifications:

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


• BSN preferred.


• Case management experience preferred

Primary Location: Maryland,Glen Burnie,Baltimore Washington Medical Center
Scheduled Weekly Hours: 8
Shift: Day
Workdays: Sat, Sun
Working Hours Start: 08:30 AM
Working Hours End: 05:00 PM
Job Schedule: Short Hour
Job Type: Standard
Worker Location: Onsite
Employee Status: Regular
Employee Group/Union Affiliation: M37|UFCW|Local 27
Job Level: Individual Contributor
Department: Baltimore Washington Med Centr - UR-Discharge Planning - 1808
Pay Range: $53.45 - $59.89 / hour The ranges posted above reflect the location in the job posting. The salary range may vary if you reside in a different location or state than the location posted.
Travel: Yes, 15 % of the Time
On-site: Work location is on-site (KP designated office, medical office building or hospital). Worker location must align with Kaiser Permanente's Authorized States policy. At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.

Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest

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