Patient Care Coordinator
On-siteGlen Burnie, Maryland, United States
Job Summary
Conduct initial face-to-face assessments for admitted members within 24 hours of admission to identify discharge needs. Document outcomes in KPHC, communicate plans with physicians and patient families, and actively participate in daily Care Without Delay rounds to report patient progression. Review and document discharge plans per facility and regulatory policies, tracking care updates and barriers daily. Collaborate with social workers to coordinate long-term care and financial assistance, while managing referrals for post-acute levels such as home health, DME, and SNF. Escalate care delays and systemic patterns requiring corrective action, ensuring follow-up appointments for high-risk patients are scheduled prior to discharge. Adhere to infection control and safety policies while maintaining professionalism with all healthcare team members. Work every other weekend with rotating holidays, requiring multiple state nursing licenses within six months of hire.
Required Qualifications
- Minimum of one (1) year in an acute medical/surgical/ED or critical care nursing area
- Associate Nursing degree required
- Registered Nurse License (Virginia) within 6 months of hire
- Registered Nurse License (Maryland) within 6 months of hire
- Compact License: Registered Nurse within 6 months of hire
- Registered Nurse License (District of Columbia) within 6 months of hire
- Experience using an electronic medical record system
- Some awareness or knowledge of health/care reimbursement systems (Medicare Advantage, Commercial payer, Medicaid and CMS regulatory rules)
- Successful completion of PCC Assessment of Critical Skills
- Passing score on inter-rater reliability
- Must be able to effectively communicate with physicians, members and their family or representatives, and hospital staff
- Ability to work independently and apply critical thinking skills for problem solving and decision making
- Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities
- Intermediate computer skills (Microsoft Office Suite proficiency)
- Ability to tolerate and cope with ambiguity
- Ability to promote teamwork and to work effectively as a team member
- Excellent verbal and written communication skills
- Ability to interact/communicate effectively with key internal and external stakeholders
- Provide excellent customer service to promote excellence in the patient experience
- Every other weekend, rotating holidays required
Desired Qualifications
- Recent acute care, case management, or home health experience preferred
- BSN preferred
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