Care Coordinator, Care Management

3 months ago

Edison, United States Hackensack Meridian Health Full time

Overview:

The Care Coordinator, Care Management is a member of the healthcare team and is responsible for coordinating, communicating, and facilitating the clinical progression of the patient's treatment and discharge plan. Accountable for a designated patient caseload; assesses, plans, and facilitates with patients, families and the multidisciplinary team to meet treatment goals, expected length of stay, and arrange for the appropriate next level of care. Oversees interfacility transitions and handoff between acute and post-acute services.

Responsibilities:

1. Assesses patients by screening for potential discharge needs regardless of race, age, sex, religion, diagnosis and ability to pay. Meets directly with patient/family to assess needs and develop an individualized care plan in collaboration with the physician and other members of the health care team.

2. Facilitates communication and coordination between members of the health care team and involves the patient and family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the plan of care.

3. Maintains current information of community resources and refers patients to those community resources appropriate for the patient's care. Consults with other community agencies and committees to identify potential resources to support patients and their families.

4. Works collaboratively with all team members of the multidisciplinary and post acute care teams to secure timely and appropriate transitions to the next level of care.

5. Develops a discharge plan, in collaboration with the patient and support persons, identifying goals that will provide maximum benefit for each patient. Ensures that the discharge plan meets the continuing care needs of the patient.

6. Documents and communicates information to the multidisciplinary team in order to coordinate and maximize care. Ensures that the medical record reflects the education provided, coordination of services, referrals made and authorizations obtained.

7. Participates actively on appropriate committees, workgroups, and or meetings.

8. Identifies and refers quality issues for review to the Quality Management Program.

9. Participates in multidisciplinary rounds, specific to assigned units. Brings forth issues which impact on discharge as well as length of stay in a timely manner, for discussion and resolution.

10. Performs appropriate reassessments and evaluates progress against care goals and the plan of care and revises plan, as needed. Ensures that the medical record reflects reassessment of the discharge plan at least weekly and upon any change in medical condition affecting the plan.

11. Provides patients and families with resources and discharge options. Educates regarding the risks and benefits of discharge options and any available health care benefits.

12. Provides appropriate CMS documents to the patient and family/support person as per regulatory guidelines (ie., Important Message 4 to 48 hours prior to discharge, appeal and HINN notices)

13. Utilizes social determinants of health screening tools and resources during each intake assessment.

14. Collaborates with all members of the multidisciplinary team to support the following functions; crisis intervention, counseling support and referrals, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, hospital throughput.

15. Referrals should be made to the following as required/needed: a. Acute rehabilitation facilities b. Sub- Acute rehabilitation facilities c. Long Term Care facilities d. Assisted Living facilities e. Adult day program f. Level 1/Level 2 PASRR screening g. EARC screening h. Home Care i. Hospice j. Durable medical equipment k. Transport l. Dialysis m. Financial assistance n. Medication assistance o. Palliative Care p. Boarding home placement q. Mental health services r. Homelessness placement s. Substance abuse placement t. Division of Child Protection and Permanency u. Adult Protective Services

16. Maintains annual competencies and ensures training and continuing education of the team in applicable platforms. (Epic, Xsolis Cortex, BI, Google Suites)

17. Other duties and/or projects as assigned.

18. Adheres to HMH Organizational competencies and standards of behavior.

Qualifications:

Education, Knowledge, Skills and Abilities Required:

1. Bachelor's Degree in Nursing or related field, or Master's Degree in Social Work.

2. Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills.

3. Excellent verbal, written and presentation skills.

4. Moderate to expert computer skills.

5. Familiar with hospital resources, community resources, and utilization management.

6. Excellent written and verbal communication skills.

7. Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.

Education, Knowledge, Skills and Abilities Preferred:

1. Master's degree.

Licenses and Certifications Required:

1. NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker.

2. Care Management certification by a nationally recognized organization within 1 year.

  • Care Coordinator, Care Management

    2 weeks ago

    Edison, New Jersey, United States Hackensack Meridian Health Full time

    Job SummaryThe Care Coordinator, Care Management is a critical member of the healthcare team responsible for coordinating, communicating, and facilitating the clinical progression of patient treatment and discharge plans. This role requires effective decision-making skills, creativity in problem-solving, and influential leadership skills to ensure timely and...

  • Care Coordinator, Care Management

    3 days ago

    Edison, New Jersey, United States Hackensack Meridian Health Full time

    Care Coordinator Job SummaryThe Care Coordinator will be a member of the healthcare team, responsible for coordinating, communicating, and facilitating the clinical progression of the patient's treatment and discharge plan. This role requires effective decision-making skills, creativity in problem-solving, and influential leadership skills.Key...

  • Care Coordinator, Care Management Specialist

    3 days ago

    Edison, New Jersey, United States Hackensack Meridian Health Full time

    Job SummaryWe are seeking a highly skilled Care Coordinator to join our team at Hackensack Meridian Health. As a key member of our healthcare team, you will be responsible for coordinating, communicating, and facilitating the clinical progression of patient treatment and discharge plans.Key ResponsibilitiesOur ideal candidate will have excellent...

  • Clinical Care Specialist

    1 month ago

    Edison, New Jersey, United States Shore Care Full time

    About This RoleAt Shore Care, we're committed to delivering exceptional patient care and advancing our mission to transform healthcare. As a Registered Nurse, you'll play a vital role in achieving this goal.Key ResponsibilitiesProvide direct care to a variety of complex patients, working collaboratively with the interdisciplinary team to achieve desired...

  • Palliative Care Nurse Practitioner

    1 week ago

    Edison, New Jersey, United States Astera Cancer Care Full time

    Palliative Care Nurse Practitioner Job SummaryAstera Cancer Care is seeking a highly skilled Palliative Care Nurse Practitioner to join our team. As a Palliative Care Nurse Practitioner, you will provide consultation and administration of specialty-level palliative care, pain management, symptom management, and supportive care to meet the needs of oncology...

  • Care Coordinator

    4 weeks ago

    Edison, New Jersey, United States Hackensack Meridian Health Full time

    Job SummaryWe are seeking a highly skilled Care Coordinator to join our team at Hackensack Meridian Health. As a Care Coordinator, you will play a critical role in coordinating, communicating, and facilitating the clinical progression of patients' treatment and discharge plans.Responsibilities:Assess patients' needs and develop individualized care plans in...

  • Care Coordinator

    3 weeks ago

    Edison, New Jersey, United States Hackensack Meridian Health Full time

    Job SummaryWe are seeking a highly skilled Care Coordinator to join our team at Hackensack Meridian Health. As a key member of our healthcare team, you will be responsible for coordinating, communicating, and facilitating the clinical progression of patients' treatment and discharge plans.ResponsibilitiesAssess patients' needs and develop individualized care...

  • Care Coordinator

    4 weeks ago

    Edison, New Jersey, United States Hackensack Meridian Health Full time

    Job SummaryWe are seeking a highly skilled and compassionate Care Coordinator to join our team at Hackensack Meridian Health. As a Care Coordinator, you will play a vital role in coordinating, communicating, and facilitating the clinical progression of patient treatment and discharge plans. You will be responsible for assessing patients, developing...

  • Care Coordinator

    3 weeks ago

    Edison, New Jersey, United States Hackensack Meridian Health Full time

    Job SummaryThe Care Coordinator is a vital member of the healthcare team, responsible for coordinating, communicating, and facilitating the clinical progression of patient treatment and discharge plans. This role requires effective decision-making skills, creativity in problem-solving, and influential leadership skills. The ideal candidate will have a...

  • Care Coordinator

    3 weeks ago

    Edison, New Jersey, United States Hackensack Meridian Health Full time

    Job SummaryWe are seeking a highly skilled Care Coordinator to join our team at Hackensack Meridian Health. The successful candidate will be responsible for coordinating, communicating, and facilitating the clinical progression of patient treatment and discharge plans.Key ResponsibilitiesAssess patients to identify potential discharge needs and develop...

  • Palliative Care Nurse Practitioner

    4 weeks ago

    Edison, United States Astera Cancer Care Full time

    Why Join Us? Increase your chances of reaching the interview stage by reading the complete job description and applying promptly.For us, what matters most is excellence. We are caring professionals, people who live, work and dedicate themselves to the communities of Central New Jersey. As such, we strive to provide a sanctuary of excellence, precision,...

  • Palliative Care Nurse Practitioner

    4 weeks ago

    Edison, United States Astera Cancer Care Full time

    Job DescriptionWhy Join Us? For us, what matters most is excellence. We are caring professionals, people who live, work and dedicate themselves to the communities of Central New Jersey. As such, we strive to provide a sanctuary of excellence, precision, thoroughness and genuine compassion. We also take a whole-person approach to patient care and treatment,...

  • Palliative Care Nurse Practitioner

    4 weeks ago

    Edison, United States Astera Cancer Care Full time

    Why Join Us? Increase your chances of reaching the interview stage by reading the complete job description and applying promptly.For us, what matters most is excellence. We are caring professionals, people who live, work and dedicate themselves to the communities of Central New Jersey. As such, we strive to provide a sanctuary of excellence, precision,...

  • Palliative Care Nurse Practitioner

    4 weeks ago

    Edison, New Jersey, United States Astera Cancer Care Full time

    About the RoleAstera Cancer Care is seeking a highly skilled Palliative Care Nurse Practitioner to join our team. As a key member of our Palliative Medicine and Supportive Care program, you will provide consultation and administration of specialty-level palliative care, pain management, symptom management, and supportive care to meet the needs of oncology...

  • Pediatric Intensive Care Nurse

    1 week ago

    Edison, New Jersey, United States Samba Care Full time

    Pediatric Intensive Care Nurse Job DescriptionSamba Care is seeking a skilled Pediatric Intensive Care Nurse to join their team. The ideal candidate will have experience in pediatric intensive care and be able to provide high-quality patient care.Key Responsibilities:Implement and maintain established department, unit, administrative, and clinical...

  • Pediatric Intensive Care Nurse

    1 week ago

    Edison, New Jersey, United States Samba Care Full time

    Samba Care is seeking a skilled Pediatric Intensive Care Nurse to join their team. The ideal candidate will have experience in pediatric critical care and be able to work independently with minimal supervision.Responsibilities:Implement and maintain established department, unit, administrative, and clinical policies/procedures for patient care, safety, and...

  • Pediatric Intensive Care Nurse

    3 weeks ago

    Edison, New Jersey, United States Samba Care Full time

    Pediatric Intensive Care Nurse Job DescriptionSamba Care is seeking a skilled Pediatric Intensive Care Nurse to join our team for a travel nursing assignment in New Jersey.Job ResponsibilitiesImplement and maintain established department, unit, administrative, and clinical policies/procedures for patient care, safety, and infection control.Conduct initial...

  • Pediatric Intensive Care Nurse

    2 weeks ago

    Edison, New Jersey, United States Samba Care Full time

    Job Title: Pediatric Intensive Care NurseSamba Care is seeking a highly skilled Pediatric Intensive Care Nurse to join our team.Job Description & RequirementsSpecialty: Pediatric Intensive CareDiscipline: Registered NurseDuration: 13 weeksShift: 8 hours, daysEmployment Type: TravelThe ideal candidate will have experience in pediatric intensive care and be...

  • Pediatric Intensive Care Nurse

    2 weeks ago

    Edison, New Jersey, United States Samba Care Full time

    Pediatric Intensive Care Nurse Job DescriptionSamba Care is seeking a skilled Pediatric Intensive Care Nurse to join our team of healthcare professionals. As a Pediatric ICU Nurse, you will be responsible for providing high-quality patient care to critically ill children.Key Responsibilities:Implement and maintain established department, unit,...

  • Pediatric Intensive Care Nurse

    1 week ago

    Edison, New Jersey, United States Samba Care Full time

    Pediatric Intensive Care Nurse Job DescriptionSamba Care is seeking a highly skilled Pediatric Intensive Care Nurse to join our team. As a travel nurse, you will have the opportunity to work in a dynamic and challenging environment, providing top-notch care to critically ill pediatric patients.Key ResponsibilitiesImplement and maintain established...