Care Coordinator, Care Management
3 days ago
We are seeking a 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. This is a challenging and rewarding opportunity to make a meaningful impact on patients' lives.
Key Responsibilities1. Assess patients' needs and develop individualized care plans in collaboration with physicians and other healthcare team members.
2. Facilitate communication and coordination between healthcare team members and involve patients and families in the decision-making process.
3. Maintain current information on community resources and refer patients to those resources appropriate for their care.
4. Work collaboratively with multidisciplinary and post-acute care teams to secure timely and appropriate transitions to the next level of care.
5. Develop discharge plans that meet patients' continuing care needs and ensure that the medical record reflects the education provided, coordination of services, referrals made, and authorizations obtained.
6. Participate in multidisciplinary rounds and bring forth issues that impact discharge and length of stay in a timely manner.
7. Perform reassessments and evaluate progress against care goals and the plan of care, revising the plan as needed.
8. Provide patients and families with resources and discharge options, educating them on the risks and benefits of discharge options and available healthcare benefits.
9. Utilize social determinants of health screening tools and resources during each intake assessment.
10. 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.
11. Make referrals to acute rehabilitation facilities, sub-acute rehabilitation facilities, long-term care facilities, assisted living facilities, adult day programs, Level 1/Level 2 PASRR screening, EARC screening, home care, hospice, durable medical equipment, transport, dialysis, financial assistance, medication assistance, palliative care, boarding home placement, mental health services, homelessness placement, substance abuse placement, Division of Child Protection and Permanency, and Adult Protective Services as required.
12. Maintain annual competencies and ensure training and continuing education of the team in applicable platforms.
13. Adhere to HMH Organizational competencies and standards of behavior.
RequirementsEducation, 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. Familiarity 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.
Preferred Qualifications1. Master's degree.
Licenses and Certifications Required1. 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.
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