JOB SUMMARY
The Patient Care Coordinator (PCC) is responsible for managing and coordinating the care of acute inpatient patients. This role involves collaboration with hospital-based physicians, patients/families, nursing staff, utilization review teams, and other healthcare professionals to ensure continuity of care, clinical effectiveness, and cost-efficient outcomes. The PCC also facilitates coordination with community providers and ambulatory case managers to ensure appropriate transition of care for safe discharges and the prevention of readmissions.

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 them to determine the appropriate transition plan with the physician healthcare team and patient/family.
• Review and document the discharge plan in accordance with relevant discharge planning documentation policies, facility policies, and regulatory requirements.
• Send referrals and communicate with in-network vendors for the coordination of post-acute levels of care, including Home Health, Durable Medical Equipment (DME), IV Infusion, Skilled Nursing Facilities (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 Centers for Medicare & Medicaid Services (CMS) regulatory rules
• Completion of PCC Assessment of Critical Skills