Care Coordinator
2 weeks ago
Hackensack Meridian Health is a leading healthcare organization that values its team members as the heart of its success. As a Care Coordinator, you will play a vital role in coordinating, communicating, and facilitating the clinical progression of patients' treatment and discharge plans. Your responsibilities will include assessing patients, developing individualized care plans, and collaborating with the multidisciplinary team to ensure timely and appropriate transitions to the next level of care.
Responsibilities- Assess patients to identify potential discharge needs and develop individualized care plans in collaboration with the physician and other healthcare team members.
- Facilitate communication and coordination between healthcare team members and involve patients and families in the decision-making process to minimize fragmentation of services and manage resources.
- Maintain current information on community resources and refer patients to those resources appropriate for their care.
- Collaborate with the multidisciplinary team to secure timely and appropriate transitions to the next level of care.
- Develop discharge plans that meet the continuing care needs of patients and ensure that the medical record reflects the education provided, coordination of services, referrals made, and authorizations obtained.
- Participate in multidisciplinary rounds and bring forth issues that impact 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 the multidisciplinary team 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.
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