JOB SUMMARY
The Patient Care Coordinator (PCC) is responsible for the oversight and coordination of care for the acute inpatient population. This role involves collaboration with hospital-based physicians, patients and families, nursing staff, utilization review, and the broader healthcare team to ensure continuity of patient care progression, aiming for both clinical and cost-effective outcomes. The PCC also facilitates and coordinates with community providers and ambulatory case managers to support appropriate levels of care and transitions for safe discharges, with the goal of preventing readmissions.

Key Responsibilities
• Completes an initial face-to-face assessment for every admitted member within 24 hours of admission to identify discharge needs.
• Documents assessment outcomes in KPHC and communicates them to determine the appropriate transition plan with the physician healthcare team and patient/family.
• Reviews and documents the discharge plan in accordance with discharge planning documentation policies, facility policies, and regulatory requirements.
• Sends referrals and communicates with in-network vendors to coordinate post-acute levels of care, including Home Health, Durable Medical Equipment (DME), IV Infusion, Skilled Nursing Facility (SNF) Sub-Acute, and Acute Rehab.

Required Qualifications
• Associate Nursing Degree
• 1 year of experience in an acute medical/surgical, Emergency Department (ED), or critical care nursing area.
• Experience using an electronic medical record system.
• Knowledge of health/care reimbursement systems, including Medicare Advantage, Commercial payer, Medicaid, and CMS regulatory rules.
• Completion of PCC Assessment of Critical Skills.