Patient Care Coordinator RN, On Call, Children's Hospital

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• Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24hrs of admission.
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• Document in KPHC and communicate the assessment outcomes to determine the appropriate transition plan with MAPMG physician healthcare team and patient/family.
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• Active participant in daily Care Without Delay (CWD) rounds reporting on patient progression towards the established discharge plan.
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• Review and document discharge plan in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.
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• Document any updates, care progression and barriers to discharge daily, and as indicated on assigned patients.
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• Manage timeliness of care progression with physician and nursing staff to prevent avoidable delays and or days.
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• Collaborate with Social Worker to coordinate, long-term care, assisted living, financial assistance, and other services, as required.
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• 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.
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• 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.
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• 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.
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• Observe all facility safety policies and procedures (infection control, Members Rights policies, and any regulatory requirements)
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• Participate in Quality Assurance duties and implementation of programs to improve care Quality Indicators.
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• Maintain professionalism with all duties in an effective and timely manner as directed or assigned by designated supervisor.
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• Consistently work cooperatively with patients, patients representatives, facility staff, physicians, consultants, and ancillary service providers.
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• Minimum of one (1) year in an acute medical/surgical/ED or critical care nursing area.
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• Associate Nursing degree required.
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  This job requires credentials from multiple states. Credentials from the primary work state are required at hire. Additional Credentials from the secondary work state(s) are required post hire.
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• Registered Nurse License (Maryland) within 6 months of hire AND Registered Nurse License (Virginia) within 6 months of hire
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OR
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  Compact License: Registered Nurse within 6 months of hire

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  Registered Nurse License (District of Columbia) within 6 months of hire
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• Basic Life Support
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• Experience using an electronic medical record system
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• Some awareness or knowledge of health/care reimbursement systems (Medicare Advantage, Commercial payer, Medicaid and CMS regulatory rules).
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• Annually: Successful completion of PCC Assessment of Critical Skills, Passing score on inter-rater reliability.
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• Must be able to effectively communicate with physicians, members and their family or representatives, and hospital staff.
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• Ability to work independently and apply critical thinking skills for problem solving and decision making.
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• Adheres to KP Employees Handbook and facility policies and procedures.
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• Must have excllent time management skills to develop organized work processess in a high-volume envirornment with rapidly changing priorities.
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• Intermediate computer skills (Microsoft Office Suite proficiency).
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• Ability to tolerate and cope with ambiguity.
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• Ability to pormote teamwork and to work effectively as a team member.
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• Excellent verbal and written communication skills.
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• Ability to interact/communicate effectively with key internal and external stake holders.
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• Provide excellent customer service to promote excellence in the patient experience.
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• Recent acute care, case management, or home health experience preferred.
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• BSN preferred.
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• Previous case management/discharge planning experience preferred
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