Patient Care Coordinator RN - Discharge Planning, On Call, BWMC
Glen Burnie, MarylandAt Kaiser Permanente our nurses are leaders, clinicians, researchers, innovators, and scientists who are contributing toward being an industry-leading voice for advancing evidence-based care. Whether supporting the patient directly in our hospitals or clinics, providing care at home, serving our patients through innovative virtual technology, or managing care delivery teams, Kaiser Permanente nurses utilize scientific evidence and our integrated care model to optimize the total health of our members and the communities we serve. We invite nurses who are passionate about nursing excellence, high-quality compassionate care delivery, professionalism, integrity, teamwork and patient and family centeredness to join our teams so that we can continue to sustain and build upon our culture of excellence.
- Job Type: Call-in/On-Call
- Job Level: Individual Contributor
- Travel: Yes, 20 % of the Time
Success Profile
We’re looking for Nurse Leaders who possess the following traits.
- Collaborative
- Compassionate
- Flexible
- Leadership
- Socially Conscientious
- Trustworthy
Benefits
We offer several benefits to our nurses.
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Medical, Vision & Dental
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Retirement Plans
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Educational Opportunities & Tuition Reimbursement
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Supportive Teams & Resources
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Career Growth & Development
Our Culture
At Kaiser Permanente, we cultivate an environment of compassion, integrity, trust, and open communication that helps our teams do their best work. We believe that lifelong learning will expand our knowledge so we can better serve our patients. Our practice is rooted in research and evidence-based care. Our nurses reflect the rich diversity of our members and communities and provide culturally responsive and competent care that promotes understanding of our members needs and preferences. At Kaiser Permanente, nurses are highly skilled professionals who exemplify leadership, critical thinking, and collaborative problem solving and deliver the right care, at the right time, in the right setting.
What Our People Are Saying
Kristen
Relief Charge Nurse
“Working as a nurse at Kaiser Permanente has allowed me the perfect flexible schedule so that I can volunteer as Girl Scout Leader and room parent for both my children. My kids know that I am a hardworking mother who can provide, as well as a mom who can be present and be there for them – and that means everything to me.”
Jazmin
RN, Advice Nurse
“Working for Kaiser Permanente has allowed me to take control of my future and make my goals a possibility. I feel that Kaiser Permanente allows me to keep climbing and moving. Having that ability truly makes me feel empowered.”
Stella
Registered Nurse IV
“Kaiser Permanente has taken me on a personal and educational growth journey. I am supported by a culture of excellence that allows me to be dedicated to patients and patients’ families every day at work. What an honor to be part of Kaiser Permanente.”.
Caitlin
Inpatient Lactation Consultant
“As an RN/IBCLC in Maternal Child, I’m meeting families at a pivotal time — I’m there to help launch a new family into the world. Everything I do has the potential to impact a family’s health for generations to come.”
Kimberly
Quality Coordinator RN
“In Hawaii, your community is your family — or ‘ohana.’ I am able to provide extraordinary patient-centered care to my ohana.”
David
Appointment and Advice RN
“The location is fantastic. Kaiser Permanente is all over the country. You can pick almost any environment you want – from ocean to mountain to city. You’ll still be able to contribute to our mission of providing high quality health care at a local facility.”
Shawn
BSN, RN
“I chose Kaiser Permanente because their staff and providers really show that they care about you. Also, throughout my 12 years of working here I’m always learning something new, and I’ve had many opportunities for growth and development.”
Patient Care Coordinator RN - Discharge Planning, On Call, BWMC
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- 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.
- Minimum of one (1) year in an acute medical/surgical/ED or critical care nursing area.
- Associate Nursing degree required.
- This job requires credentials from multiple states. Credentials from the primary work state are required before hire. Additional Credentials from the secondary work state(s) are required post hire.
- Registered Nurse License (Maryland) within 6 months of hire AND Registered Nurse License (Virginia) 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
- 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 excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
- Intermediate computer skills (Microsoft Office Suite proficiency).
- Ability to tolerate and cope with ambiguity.
- Ability to promote 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.
- Recent acute care, case management, or home health experience preferred.
- BSN preferred.
- Case Management Experience Preferred.
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest
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