Care Coordinator, Care Management

3 weeks ago


Edison, New Jersey, United States Hackensack Meridian Health Full time

Care Coordinator Job Summary

The Care Coordinator will be 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 resources appropriate for their care.
  • Work collaboratively with the multidisciplinary team 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 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, and bring forth issues that impact discharge and length of stay in a timely manner.
  • Perform appropriate 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 regarding the risks and benefits of discharge options and any available healthcare benefits.
  • 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 crisis intervention, counseling support and referrals, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, hospital throughput, and other functions as required.
  • 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, Adult Protective Services, and other resources as needed.
  • Maintain annual competencies and ensure training and continuing education of the team in applicable platforms.
  • Perform other duties and/or projects as assigned.
  • Adhere to Hackensack Meridian Health Organizational competencies and standards of behavior.

Qualifications:

  • Bachelor's Degree in Nursing or related field, or Master's Degree in Social Work.
  • Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills.
  • Excellent verbal, written, and presentation skills.
  • Modest 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.

Preferred Qualifications:

  • Master's degree.

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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