Job Summary Ensure patients receive the right level of care at the right time. Responsible for working with the referring physician, patient/family, acute hospital health care professionals and case management associates, external agencies when indicated and other MedStar Health care providers to promote a smooth, efficient and customer focused transition from acute care to post acute care services. Enhances the patient experience through effective and efficient patient care coordination using established criteria to determine appropriateness of post acute services. Works with the patient/family, physician, inpatient case managers and other MedStar Health care providers to determine the most applicable post acute environment(s)(comprehensive inpatient rehab (CIR), subacute, home care and outpatient rehab) facilitating timely and medically appropriate transfer from the acute care hospital. When more than one post acute care service is expected for the patients return to maximum function, the Patient Care Coordinator communicates that information to the patient/family and to all post-acute providers expected to be involved in the continual care of the patient. Minimum Qualifications Education/Training Bachelors required, Masters preferred in Social Work, counseling, vocational rehabilitation, or other appropriately qualified clinician as defined by CMS. Experience 3 years experience preferred. License/Certification/Registration At least one valid license in Maryland, the District of Columbia or Virginia as appropriate for respective work location. For Social Workers LSWA, LGSW, or LCSW; LICSW preferred. For vocational counselors: CRC orCCM. Knowledge, Skills & Abilities Excellent verbal and written communication skills. Basic computer skills required. Demonstrates leadership skills, including self-initiative and the establishment of efficient and effective organization and staffing structures and process for planning, directing, problem-solving, and team-building. Primary Duties and Responsibilities Adheres to policies, procedures, quality standards, and safety standards of each of the hospitals and MedStar entities with which they are assisting with patient throughput. Collaborates with the referring and attending physicians, health care professionals, case management and the patient/family to develop and facilitate the post-acute care plan. Communicates with the patient, their caregivers, physicians, hospital case managers and health care professionals to facilitate a smooth and timely transition of the patient from acute to post-acute care. Contributes to the achievement of established goals and objectives of the acute care hospitals by assisting with the transition of care between the various levels of care in the MedStar post-acute care delivery system and our community partners. Complies with governmental and accreditation regulations. Completes annual Code of Conduct, Compliance and other mandatory training. Coordinates the services of the post-acute care plan in cooperation with appropriate MedStar associates and businesses. Educates patients/family, physicians and other referral sources on post-acute care programs, services and the care coordination process. Follows through on assignments. Punctual and manages own time well. Monitors progress toward achievement of goals and budgets. Pays attention to details. Utilize data to solve business problems. Informs and educates patients/family on post-acute plan-of-care and what to expect throughout the transition from one level of care to another. Maintains ongoing relationships with physicians and other referral sources and contributes to creating an environment of teamwork and trust among all associates. Offers patients/families choice of post-acute providers in determining the final plan-of-care and appropriately documents that choice in the patients medical record. Participates in meetings as appropriate to advance the post-acute care coordination process. Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings, serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate. Participates in the development, coordination and ongoing evaluation of patient education programs and materials. Performs daily routines including monitoring daily census and surgical schedules, attending appropriate unit rounds, keeping detailed daily logs/statistics regarding patients being followed, keeping work load organized and prioritized. Performs other duties as assigned. Utilizes technology to effectively maximize efficiency, accuracy and communication of referrals. Is proactive in developing good workflow practices. About MedStar Health MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, DC, region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.