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Care Coordinator, Care Management Specialist
2 months ago
At Hackensack Meridian Health, we are seeking a highly skilled and compassionate Care Coordinator, Care Management to join our team. 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 care transitions.
- Communication and Coordination: Facilitate communication between healthcare teams, patients, and families to minimize fragmentation of services and ensure timely and appropriate care.
- Community Resource Referral: Maintain current information on community resources and refer patients to those resources that best meet their needs.
- Discharge Planning: Develop discharge plans that meet patients' continuing care needs, ensuring a smooth transition to the next level of care.
- Documentation and Communication: Document and communicate information to healthcare teams to coordinate and maximize care, ensuring the medical record reflects education provided, coordination of services, referrals made, and authorizations obtained.
- Quality Improvement: Identify and refer quality issues for review to the Quality Management Program, participating in multidisciplinary rounds and bringing forth issues impacting discharge and length of stay.
- Education and Support: Provide patients and families with resources and discharge options, educating them on the risks and benefits of discharge options 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, and hospital throughput.
- Education: BSN or BSN in progress, or Master's Degree in Social Work.
- Skills: Effective decision-making, creativity in problem-solving, influential leadership, excellent verbal, written, and presentation skills, moderate to expert computer skills, familiarity with hospital resources, community resources, and utilization management.
- Certifications: NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker. Care Management, CCMA, or ACMA certification strongly preferred.
