An All-Inclusive Opportunity! 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 To optimize your experience applying to a job at Kaiser Permanente, we have created a unique and easy all-inclusive process to apply opportunities in this specific specialty for this Service Area relevant to your work experience and interests. This position has been created to source and attract external candidates for current positions that remain unfilled within the organization. If you are a current employee, please visit the careers website for a complete listing of available positions. So, what is next? • We have a team dedicated to reviewing submissions for an expedited hiring experience. See what it-s all about, submit your interest today! -May be entitled to translation/bilingual, shift or other wage premiums as governed by the applicable collective bargaining agreement. Please refer to the respective collective bargaining agreement for additional information on such wage premiums: https://www.lmpartnership.org/local-contracts. 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.