Registered Nurse – Case Management- Case Manager

The Patient Care Coordinator is responsible for overseeing the management and coordination of care for the acute inpatient population. The PPC 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 progressions 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. Responsibilities: -Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24 hours of admission. -Document in KPHC and communicate the assessment outcomes to determine the appropriate transition plan with MAPMG physician healthcare team and patient/family. Review and document discharge plan in accordance with KP discharge planning documentation policies, facility policies and regulatory requirements. -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.