Patient Care Coordinator

Kaiser Permanente; Lanham (MD); Presencial; USD 52 000 - 64 000; Tempo integral

Resumo da oferta

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.

Qualificações

• 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.

Responsabilidades

• 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.

Descrição da oferta de emprego

every other weekend required

Week 1: Sun-Sat; Week 2: Sun-Sat

Job Summary:

The Patient Care Coordinator is responsible for overseeing the management and coordination of care for the acute inpatient population. The PCC collaborates with rounding MAPMG Hospital Based Service Physicians, patient/family, nursing, utlization review and other members of the healthcare team to assure continuum of patient care progression for clinical and cost-effective outcomes. The PCC facilitates and coordinates with community providers and ambulatory case managers to assist with the appropriate level and transition of care for a safe discharge and preventing a re-admission.

Essential Responsibilities:

• Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24hrs of admission.
• Document in KPHC and communicate the assessment outcomes to determine the appropriate transition plan with MAPMG physician healthcare team and patient/family.
• Active participant in daily Care Without Delay (CWD) rounds reporting on patient progression towards the established discharge plan.
• Review and document discharge plan in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.
• Document any updates, care progression and barriers to discharge daily, and as indicated on assigned patients.
• Manage timeliness of care progression with physician and nursing staff to prevent avoidable delays and or days.
• Collaborate with Social Worker to coordinate, long-term care, assisted living, financial assistance, and other services, as required.
• Send referrals/communicate with in-network vendors for coordination of post-acute levels of care such as Home Health, DME, IV infusion, SNF, Sub-Acute and Acute Rehab.
• Timely identification, recording, and escalation of delays in care and barriers to discharge. Provide solutions to correct delays and recognize systemic patterns that require corrective action.
• Assure follow up appointments and referrals to ambulatory case manager for high-risk patient population are scheduled and communicated to patient/family prior to discharge.
• Observe all facility safety policies and procedures (infection control, Members Rights policies, and any regulatory requirements)
• Participate in Quality Assurance duties and implementation of programs to improve care Quality Indicators.
• Maintain professionalism with all duties in an effective and timely manner as directed or assigned by designated supervisor.
• Consistently work cooperatively with patients, patients representatives, facility staff, physicians, consultants, and ancillary service providers.