JOB SUMMARY
The Patient Care Coordinator is responsible for managing and coordinating the care of acute inpatient patients. This role involves collaborating with hospital-based physicians, patients, families, nursing staff, utilization review, and other healthcare team members to ensure continuity of care, clinical effectiveness, and cost-efficient outcomes. The Coordinator also facilitates and coordinates with community providers and ambulatory case managers to ensure appropriate post-discharge care settings and smooth transitions to prevent readmissions.

Key Responsibilities
• Complete an initial face-to-face assessment for every admitted member within 24 hours to identify discharge needs.
• Document assessment outcomes in the electronic medical record and communicate them to determine the appropriate transition plan with the healthcare team and patient/family.
• Review and document discharge plans in accordance with relevant policies and regulatory requirements.
• Send referrals and communicate with in-network vendors for the coordination of post-acute levels of care, including Home Health, DME, IV Infusion, SNF Sub-Acute, and Acute Rehab.

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