Care Coordinator, Care Management
7 days ago
We are seeking a highly skilled and compassionate Care Coordinator, Care Management 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.
Responsibilities- Assess patients' needs and develop individualized care plans in collaboration with physicians and other healthcare team members.
- Facilitate communication and coordination between healthcare team members and involve patients and families in the decision-making process.
- Maintain current information on community resources and refer patients to those resources appropriate for their care.
- Work collaboratively with multidisciplinary and post-acute care teams to secure timely and appropriate transitions to the next level of care.
- Develop discharge plans that meet patients' continuing care needs and ensure that the medical record reflects education provided, coordination of services, referrals made, and authorizations obtained.
- Participate in multidisciplinary rounds and bring forth issues impacting discharge and length of stay in a timely manner.
- Perform reassessments and evaluate progress against care goals and the plan of care, revising the plan as needed.
- Provide patients and families with resources and discharge options, educating them on the risks and benefits of discharge options and available healthcare benefits.
- Utilize social determinants of health screening tools and resources during each intake assessment.
- Collaborate with multidisciplinary teams to support crisis intervention, counseling support, and referrals, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, and hospital throughput.
- BSN or BSN in progress and/or willing to acquire within 3 years of hire or transfer into the position; or Masters Degree in Social Work.
- Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills.
- Excellent verbal, written, and presentation skills.
- Moderate to expert computer skills.
- Familiar with hospital resources, community resources, and utilization management.
- Excellent written and verbal communication skills.
- Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.
- Master's degree.
- NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker.
- Care Management, CCMA or ACMA certification strongly preferred.
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