JOB SUMMARY
The Patient Care Coordinator (PCC) is responsible for managing and coordinating the care of the acute inpatient population. This role involves collaboration with physicians, patients, families, nursing staff, utilization review, and other healthcare team members to ensure continuity and effectiveness of patient care transitions, aiming for clinical and cost-effective outcomes. The PCC also facilitates and coordinates with community providers and ambulatory case managers to ensure safe discharges and prevent readmissions by arranging appropriate levels of care.

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 healthcare team and patient/family.
• Reviews and documents the discharge plan in accordance with relevant policies and regulatory requirements.
• Sends referrals and communicates 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