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Care Coordinator, Care Management
1 month ago
Job Summary:
The Care Coordinator, Care Management is 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 Responsibilities:- Assess patients by screening for potential discharge needs, regardless of race, age, sex, religion, diagnosis, and ability to pay.
- Develop an individualized care plan in collaboration with the physician and other members of the healthcare team.
- Facilitate communication and coordination between members of the healthcare team and involve the patient and family in the decision-making process.
- Maintain current information of community resources and refer patients to those community resources appropriate for the patient's care.
- Work 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.
- Develop a discharge plan, in collaboration with the patient and support persons, identifying goals that will provide maximum benefit for each patient.
- Document and communicate information to the multidisciplinary team in order to coordinate and maximize care.
- Participate actively on appropriate committees, workgroups, and meetings.
- Identify and refer quality issues for review to the Quality Management Program.
- Participate in multidisciplinary rounds, specific to assigned units.
- Perform appropriate reassessments and evaluate progress against care goals and the plan of care and revise plan, as needed.
- Provide patients and families with resources and discharge options.
- Provide appropriate CMS documents to the patient and family/support person as per regulatory guidelines.
- Utilize social determinants of health screening tools and resources during each intake assessment.
- Collaborate 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.
- Referrals should be made to the following as required/needed: acute rehabilitation facilities, sub-acute rehabilitation facilities, long-term care facilities, assisted living facilities, adult day program, 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, Adult Protective Services.
- Maintain annual competencies and ensure training and continuing education of the team in applicable platforms.
Qualifications:
Education, Knowledge, Skills and Abilities Required:
- 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.
Education, Knowledge, Skills and Abilities Preferred:
Masters degree.
Licenses and Certifications Required:
NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker.
Licenses and Certifications Preferred:
Care Management, CCMA or ACMA certification strongly preferred.
