RN Patient Care Coordinator in Arlington, VA

Position Overview

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, utilization 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 to prevent re-admission.

Key Responsibilities

• Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24hrs of admission.
• Documents in KPHC and communicates assessment outcomes to determine the appropriate transition plan with MAPMG physician healthcare team and patient/family.
• Participates actively in daily Care Without Delay (CWD) rounds, reporting on patient progression towards the established discharge plan.
• Reviews and documents discharge plans in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.
• Documents any updates, care progression, and barriers to discharge daily, as indicated for assigned patients.
• Manages timeliness of care progression with physician and nursing staff to prevent avoidable delays or extended days.
• Collaborates with the Social Worker to coordinate long-term care, assisted living, financial assistance, and other necessary services.
• Sends referrals and communicates 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.
• Identifies, records, and escalates delays in care and barriers to discharge, providing solutions to correct delays and recognizing systemic patterns that require corrective action.
• Ensures follow-up appointments and referrals to ambulatory case managers for high-risk patients are scheduled and communicated to patient/family before discharge.
• Observes all facility safety policies and procedures, including infection control, Members Rights policies, and regulatory requirements.
• Participates in Quality Assurance duties and the implementation of programs to improve care Quality Indicators.
• Maintains professionalism by executing all duties effectively and in a timely manner as directed by the designated supervisor.
• Works cooperatively with patients, patient representatives, facility staff, physicians, consultants, and ancillary service providers.

Required Qualifications

• Experience Required: Minimum of one (1) year in an acute medical/surgical/ED or critical care nursing area.
• Education: Associate Nursing degree required.
• Requirements: This job requires credentials from multiple states; credentials from the primary work state are required at hire and additional credentials from secondary work state(s) are required post hire. Registered Nurse License (Virginia) within 6 months of hire and Registered Nurse License (Maryland) within 6 months of hire OR Compact License: Registered Nurse within 6 months of hire; Registered Nurse License (District of Columbia) within 6 months of hire; Basic Life Support.
• Requirements: Experience using an electronic medical record system; awareness of health/care reimbursement systems (Medicare Advantage, Commercial payer, Medicaid, and CMS regulatory rules); annual completion of the PCC Assessment of Critical Skills with a passing score on inter-rater reliability; effective communication skills with physicians, members, their families, and hospital staff; ability to work independently and apply critical thinking for problem solving and decision making; adherence to KP Employees Handbook and facility policies; excellent time management in a high-volume environment with rapidly changing priorities; intermediate computer skills (Microsoft Office Suite proficiency); tolerance for ambiguity; teamwork and collaboration; and excellent verbal and written communication skills to interact effectively with key internal and external stakeholders while providing outstanding customer service.
• Schedule: Every other weekend & Holiday.

Preferred Qualifications

• Recent acute care, case management, or home health experience preferred.
• BSN preferred.
• Inpatient Discharge Planning experience preferred.