Description:Multiple Locations Available:- Swedish Medical Center
- Sky Ridge Medicakl Center
- HealthOne Medical Center of Aurora
- HealthOne Presbyterian St. Lukes
- St. Anthony's Central Hospital
- St. Anthony's North Hospital
Job Summary:The Patient Care Coordinator (PCC) plays a vital role in managing and coordinating care for patients in the hospital setting. By collaborating with Colorado Permanente Medical Group (CPMG) Hospital Medicine physicians, as well as engaging with patients, families, non-KP physicians, and the case management team, the PCC ensures a seamless continuum of care that emphasizes both clinical effectiveness and cost efficiency. The PCC aims to facilitate appropriate care transitions, thereby promoting safe discharges and minimizing the risk of readmission. The Structured Admission Review (SAR) Registered Nurse (RN) partners with KP hospital stakeholders in status and length of stay recommendations.
Essential Responsibilities:- Review KP emergency department (ED), observation, readmission, and potential long length of stay (LOS) patients to assess discharge needs within 48 hours of admission.
- Actively participate in daily hospital multi-disciplinary rounds (MDRs), reporting on care coordination needs and barriers to discharge.
- Ensure timely identification, escalation, and documentation of care coordination delays.
- Complete a Structured Admission Review (SAR), use Milliman Care Guidelines on all KP observation patients, and provide a status recommendation to the KP Triage physician.
- Coordinate with physicians and the case management team to ensure timely care progression and prevent avoidable delays or extended hospital stays.
- Collaborate with the hospital case management team and Kaiser physicians to coordinate discharge needs.
- Ensure follow-up appointments and referrals for high-risk patients are scheduled and communicated to the patient and family prior to discharge.
- Meet with patients and family members as needed to discuss available KP and community resources, follow-up appointments, and discharge plans.
- Communicate with hospital teams and in-network vendors for coordination of Durable Medical Equipment (DME) following discharge.
- Communicate with hospital teams and in-network vendors to coordinate discharge to post-acute levels of care (e.g., Home Health, Assisted Living Facility, Skilled Nursing Facility, etc.).
- Send referrals and communicate with in-network vendors for coordination of care.
- Document in HealthConnect and communicate care coordination outcomes to establish the appropriate transition plan with the CPMG physician healthcare team, the hospital case management team, and the patient/family.
- Review and document the discharge plan according to Kaiser policies and regulatory requirements.
- Identify solutions to address delays; recognize, escalate, and document recurring patterns requiring corrective action.
- Provide virtual support to non-core contracted hospitals with KP patients.
- Be proficient in the use of Milliman Care Guidelines.
- Adhere to all hospital policies and procedures, as well as regulatory requirements, including those related to infection control and the rights and responsibilities of patients and their families.
- Maintain professionalism with all duties in an effective and timely manner as directed or assigned by the designated supervisor.
- Work collaboratively with patients, their representatives, facility staff, physicians, consultants, and ancillary service providers.
- Perform additional duties as assigned.
Basic Qualifications: Experience
- Minimum 2 years of acute medical/surgical/ED or critical care nursing area.
Education
- Associates degree in Nursing.
License, Certification, Registration
- Registered Nurse License (Colorado)
Preferred Qualifications: - Bachelors degree in nursing (BSN).
- Accredited Case Manager (ACM) Certification from the American Case Management Association (ACMA) or Certified Case Manager (CCM).
- Case Management or Care Coordination.
- 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).
- Annually: 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.
- Adheres to KP Employees Handbook and facility policies and procedures.
- 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 patient experience.
Primary Location: Colorado,Denver,Regional Office - Colorado
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri, Sat, Sun (Varies)
Working Hours Start: Variable
Working Hours End: Variable
Job Schedule: Full-time
Job Type: Standard
Worker Location: Onsite
Employee Status: Regular
Employee Group/Union Affiliation: C02|UFCW|Local 7
Job Level: Individual Contributor
Department: Waterpark I - Hosp Admin-Hospital Services - 1608
Pay Range: $49.17 - $57.83 / hour Kaiser Permanente strives to offer a market competitive total rewards package and is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not reflect the full value of our total rewards package. Actual base pay determined at offer will be based on labor market data, internal alignment, and a candidate's years of relevant work experience, education, certifications, skills, and geographic location.
Travel: Yes, 15 % of the Time
On-site: Work location is on-site (KP designated office, medical office building or hospital). Worker location must align with Kaiser Permanente's Authorized States policy.
