Discharge & Care Coordination Specialist

Kaiser Permanente; Lanham (MD); On-site; USD 52,000 - 64,000; Full time

Job summary

The Patient Care Coordinator at Talentify oversees care management for the acute inpatient population and works with rounding MAPMG Hospital Based Service Physicians, patient/family, nursing, utilization review, and the healthcare team to ensure continuum of care for clinical and cost-effective outcomes.

The role coordinates with community providers and ambulatory case managers to determine appropriate levels of care and ensure a safe discharge, aiming to prevent readmissions and delays in care.

Qualifications

• Responsible for coordinating care for acute inpatient population.
• Collaborates with physicians, nursing, utilization review, patients and families to ensure continuity of care and cost-effective outcomes.

Responsibilities

• Completes an initial face-to-face assessment for admitted patients to identify discharge needs within 24 hours.
• Documents assessments and communicates outcomes to plan appropriate discharge with care team.
• Participates in daily rounds reporting patient progression toward discharge.
• Reviews and documents discharge plans per policy and regulatory requirements.
• Monitors care progression and escalates delays with the team to avoid unnecessary days.
• Coordinate with Social Worker and ambulatory case managers for post-acute care and transitions.
• Facilitate referrals to in-network vendors for post-acute services such as Home Health, DME, SNF, and rehab.
• Ensure follow up appointments and referrals are communicated to patient/family prior to discharge.
• Adhere to infection control, patient rights, and regulatory requirements.
• Support quality assurance initiatives and maintain professional conduct and teamwork.

Job description

The Patient Care Coordinator at Talentify oversees care management for the acute inpatient population and works with rounding MAPMG Hospital Based Service Physicians, patient/family, nursing, utilization review, and the healthcare team to ensure continuum of care for clinical and cost-effective outcomes.

The role coordinates with community providers and ambulatory case managers to determine appropriate levels of care and ensure a safe discharge, aiming to prevent readmissions and delays in care.