Patient Care Coordinator RN, Tyson's MOB

Company: Kaiser Permanente
Location: Mc Lean
Posted on: February 25, 2026

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. 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: Every other weekend; Alternating holidays

Keywords: Kaiser Permanente, Rockville , Patient Care Coordinator RN, Tyson's MOB, Healthcare , Mc Lean, Maryland