JOB SUMMARY
The Patient Care Coordinator (PCC) is accountable for managing and coordinating the care of acutely ill inpatients. The PCC works collaboratively with physicians, patients/families, nursing staff, utilization review teams, and other healthcare professionals to ensure seamless patient care progression, promoting both clinical effectiveness and cost-efficiency. The role involves facilitating coordination with community providers and ambulatory case managers to ensure appropriate care transitions and safe discharges, thereby preventing readmissions.

Key Responsibilities
• Complete initial face-to-face assessments for all admitted members within 24 hours of admission to identify discharge needs.
• Document assessment outcomes in the electronic medical record and communicate findings to determine appropriate transition plans with the healthcare team and patient/family.
• Review and document discharge plans in accordance with relevant 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, 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, and Medicaid, as well as CMS regulatory rules.
• Completion of the PCC Assessment of Critical Skills.