RN Care Coordination: Discharge & Transitions Specialist

kp; Silver Spring (MD); On-site; USD 70,000 - 90,000; Full time

Job summary

KP is seeking a Patient Care Coordinator to oversee the coordination of care for acute inpatient populations. The role involves collaboration with physicians, nursing, utilization review, and family communication to ensure safe discharge and prevent readmission.

Responsibilities include discharge planning, care progression documentation, and post-acute referrals. Requires RN licensure in Maryland with multi-state eligibility and EMR experience.

Qualifications

• Minimum of one year in an acute medical/surgical/ED or critical care nursing area.
• Associate Nursing degree required.
• RN license in Maryland within 6 months of hire; multiple-state licenses may be required.

Responsibilities

• Complete an initial face-to-face assessment within 24 hours of admission to identify discharge needs.
• Document in KPHC and communicate outcomes to determine the transition plan.
• Participate in daily Care Without Delay rounds and track progress toward discharge.
• Review discharge plan for compliance with policies and regulatory requirements.
• Coordinate with social work to arrange long-term care, financial assistance and services.
• Arrange post-acute referrals with in-network vendors (Home Health, SNF, rehab).

Skills

Care coordination

Communication

Electronic Medical Records (EMR) usage

Critical thinking

Team collaboration

Education

Associate Nursing degree

BSN preferred

Registered Nurse License (Maryland)

Registered Nurse License (Virginia)

Compact License

Registered Nurse License (District of Columbia)

Tools

EMR system (EPIC)

Job description

KP is seeking a Patient Care Coordinator to oversee the coordination of care for acute inpatient populations. The role involves collaboration with physicians, nursing, utilization review, and family communication to ensure safe discharge and prevent readmission.

Responsibilities include discharge planning, care progression documentation, and post-acute referrals. Requires RN licensure in Maryland with multi-state eligibility and EMR experience.