Care Coordinator, Care Management Specialist

5 days ago

Edison New Jersey, United States Hackensack Meridian Health Full time
About the Role

We are seeking a highly skilled and compassionate Care Coordinator to join our team at Hackensack Meridian Health. As a key member of our healthcare team, you will play a vital role in coordinating, communicating, and facilitating the clinical progression of patients' treatment and discharge plans.

Key Responsibilities
  • Assessment and Planning: Assess patients' needs, develop individualized care plans, and collaborate with physicians and healthcare teams to ensure seamless transitions.
  • Communication and Coordination: Facilitate communication between healthcare teams, patients, and families to minimize fragmentation of services and ensure effective care.
  • Community Resource Referral: Maintain current information on community resources and refer patients to appropriate services, consulting with other agencies and committees as needed.
  • Discharge Planning: Develop discharge plans in collaboration with patients and support persons, identifying goals that provide maximum benefit and ensuring continuity of care.
  • Documentation and Communication: Document and communicate information to healthcare teams, ensuring that medical records reflect education provided, coordination of services, referrals made, and authorizations obtained.
  • Quality Improvement: Identify and refer quality issues for review to the Quality Management Program and participate in multidisciplinary rounds to discuss and resolve issues impacting discharge and length of stay.
  • Education and Support: Provide patients and families with resources and discharge options, educating them on risks and benefits and available healthcare benefits.
  • CMS Documentation: Provide patients and families with CMS documents as per regulatory guidelines.
  • Social Determinants of Health: Utilize social determinants of health screening tools and resources during each intake assessment.
  • Collaboration and Referral: Collaborate with healthcare teams to support crisis intervention, counseling support, and referrals, as well as abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, hospital throughput, and other functions.
Requirements
  • Education: Bachelor's Degree in Nursing or related field, or Master's Degree in Social Work.
  • Skills and Abilities: Effective decision-making skills, creativity in problem-solving, influential leadership skills, excellent verbal, written, and presentation skills, moderate to expert computer skills, familiarity with hospital resources, community resources, and utilization management.
  • Licenses and Certifications: NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker, Care Management certification by a nationally recognized organization within 1 year.

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