Patient Care Coordinator

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.

- 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.