JOB SUMMARY
The Patient Care Coordinator (PCC) is responsible for managing and coordinating the care of acute inpatient patients. This role involves collaboration with physicians, patients, families, nursing staff, utilization review, and other healthcare team members to ensure continuity of care and achieve clinical and cost-effective outcomes. The PCC also facilitates and coordinates with community providers and ambulatory case managers to ensure appropriate care transitions for safe discharges and 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 them to determine the appropriate transition plan with the physician healthcare team and patient/family.
• Review and document discharge plans in accordance with 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, DME, IV Infusion, SNF Sub-Acute, and Acute Rehab.

Required Qualifications
• Associate Nursing Degree
• 1 year in an acute medical/surgical/ED or critical care nursing area
• Experience using an electronic medical record system
• Knowledge of health/care reimbursement systems (Medicare Advantage, Commercial payer, Medicaid, and CMS regulatory rules)
• Completion of PCC Assessment of Critical Skills