Patient Care Coordinator, Healthcare Management
1 week ago
At Hackensack Meridian Health, our team members are the foundation of our success.
We are dedicated to enhancing the lives of our patients by promoting healthier lifestyles, while also fostering an environment where our employees can thrive.
Our culture emphasizes connection and collaboration, ensuring that our employees are valued team members. Here, competitive benefits are just the start; we prioritize mutual support and community engagement.Together, we strive for continuous improvement, advancing our mission to revolutionize healthcare and lead positive change.
The Patient Care Coordinator, Healthcare Management plays a crucial role within the healthcare team, responsible for orchestrating, communicating, and facilitating the clinical progression of patients' treatment and discharge plans.
This role is accountable for a specific patient caseload, assessing, planning, and collaborating with patients, families, and the multidisciplinary team to achieve treatment objectives, manage expected lengths of stay, and arrange suitable next steps in care.
This position oversees transitions between facilities and ensures smooth handoffs between acute and post-acute services.Responsibilities
A typical day for a Patient Care Coordinator, Healthcare Management at Hackensack Meridian Health includes:
Conducting assessments of patients by identifying potential discharge needs, irrespective of race, age, gender, religion, diagnosis, or financial status.
Engaging directly with patients and their families to evaluate needs and develop personalized care plans in partnership with physicians and other healthcare professionals.
Facilitating communication and coordination among healthcare team members while involving patients and families in decision-making processes to reduce service fragmentation, manage resources effectively, and eliminate barriers to care.
Maintaining up-to-date knowledge of community resources and referring patients to those that are suitable for their care. Collaborating with community agencies and committees to identify potential resources that can support patients and their families.Working in partnership with all members of the multidisciplinary and post-acute care teams to ensure timely and appropriate transitions to the next level of care.
Creating discharge plans in collaboration with patients and their support systems, establishing goals that maximize benefits for each individual.
Ensuring that discharge plans adequately address the ongoing care needs of patients.Documenting and communicating relevant information to the multidisciplinary team to optimize care coordination. Ensuring that medical records accurately reflect the education provided, services coordinated, referrals made, and authorizations secured.
Actively participating in relevant committees, workgroups, and meetings.
Identifying and referring quality concerns for review to the Quality Management Program.
Engaging in multidisciplinary rounds specific to assigned units.
Addressing issues that affect discharge and length of stay promptly for discussion and resolution.
Conducting necessary reassessments and evaluating progress against care goals and plans, making adjustments as required.Ensuring that medical records reflect the reassessment of discharge plans at least weekly and whenever there is a change in medical condition impacting the plan.
Providing patients and families with resources and options for discharge. Educating them about the risks and benefits of available discharge options and any relevant healthcare benefits.Providing appropriate CMS documents to patients and families/support persons as per regulatory guidelines.
Utilizing social determinants of health screening tools and resources during each intake assessment.Collaborating with all members of the multidisciplinary team to support functions such as crisis intervention, counseling, referrals, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, and hospital throughput.
Referrals may include: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
Adult Protective Services
Maintaining annual competencies and ensuring ongoing training and education for the team in relevant platforms.
Other duties and/or projects as assigned.Adhering to organizational competencies and standards of behavior.
Qualifications
Education, Knowledge, Skills, and Abilities Required:
BSN or BSN in progress, or a willingness to obtain within three years of hire; or a Master's Degree in Social Work.
Demonstrated effective decision-making skills, creativity in problem-solving, and influential leadership abilities.Excellent verbal, written, and presentation skills.
Moderate to advanced computer proficiency.
Familiarity with hospital and community resources, as well as utilization management.
Exceptional written and verbal communication skills.
Proficient in computer skills, including Microsoft Office and/or Google Suite platforms.
Education, Knowledge, Skills, and Abilities Preferred:
Master's 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 is strongly preferred.
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