JOB SUMMARY
The Patient Care Coordinator (PCC) is accountable for managing and coordinating the care for acutely ill inpatients. This role involves collaborating with hospital-based physicians, patients, families, nursing staff, utilization review teams, and other healthcare professionals to ensure a seamless continuum of patient care, leading to optimal clinical and cost-effective outcomes. The PCC also facilitates and coordinates with community providers and ambulatory case managers to ensure appropriate care transitions and safe discharges, aiming to prevent re-admissions.

Key Responsibilities
• Complete an initial face-to-face assessment for every admitted member within 24 hours of admission to identify discharge needs.
• Document assessment outcomes in KPHC and communicate these to determine the appropriate transition plan with the physician healthcare team and patient/family.
• Review and document the discharge plan in accordance with discharge planning documentation policies, facility policies, and regulatory requirements.
• Send referrals and communicate with in-network vendors to coordinate 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, Emergency Department, 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