JOB SUMMARY
The Patient Care Coordinator (PCC) is responsible for managing and coordinating the care of acutely ill inpatients. The PCC collaborates with hospital-based physicians, patients and families, nursing staff, utilization review teams, and other healthcare professionals to ensure a seamless continuum of care, promoting positive clinical and cost-effective outcomes. This role also involves facilitating and coordinating with community providers and ambulatory case managers to ensure appropriate transitions of care, safe discharges, and the prevention of 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 healthcare team and patient/family.
• Reviews and documents the discharge plan in accordance with discharge planning policies, facility 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, including Medicare Advantage, Commercial payer, Medicaid, and CMS regulatory rules
• Completion of PCC Assessment of Critical Skills