JOB SUMMARY
The Patient Care Coordinator (PCC) is responsible for the comprehensive management and coordination of care for the acute inpatient population. This role involves close collaboration with hospital-based physicians, patients and their families, nursing staff, utilization review teams, and other healthcare professionals to ensure a seamless continuum of care and promote both clinical and cost-effective patient outcomes. The PCC plays a vital role in facilitating and coordinating with community providers and ambulatory case managers to ensure the appropriate level of care and smooth transitions, thereby promoting safe discharges and preventing 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 physician healthcare team and patient/family.
• Reviews and documents discharge plans in accordance with applicable policies and regulatory requirements.
• Sends referrals and communicates with in-network vendors for the coordination of 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, Medicaid, and CMS regulatory rules.
• Completion of PCC Assessment of Critical Skills.