Patient Care Coordinator RN, Virginia Hospital Center
Company: Kaiser Permanente
Location: State Farm
Posted on: January 1, 2026
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Job Description:
Description: Job Summary: 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. Essential Responsibilities: 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. Every other weekend & Holiday
Requirements Basic Qualifications: Experience Minimum of one (1)
year in an acute medical/surgical/ED or critical care nursing area.
Education Associate Nursing degree required. License,
Certification, Registration 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. 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 Additional
Requirements: 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 excllent time
management skills to develop organized work processess in a
high-volume envirornment with rapidly changing priorities.
Intermediate computer skills (Microsoft Office Suite proficiency).
Ability to tolerate and cope with ambiguity. Ability to pormote
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 stake holders. Provide
excellent customer service to promote excellence in the patient
experience. Preferred Qualifications: Recent acute care, case
management, or home health experience preferred. BSN preferred.
Notes: Inpatient Discharge Planning experience preferred
Keywords: Kaiser Permanente, Tuckahoe , Patient Care Coordinator RN, Virginia Hospital Center, Healthcare , State Farm, Virginia
