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Care Coordinator, Care Management Specialist
2 months ago
We are seeking a highly skilled and compassionate Care Coordinator, Care Management to join our team at Hackensack Meridian Health. 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.
Responsibilities- Assess patients' needs and develop individualized care plans in collaboration with physicians 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.
- Work collaboratively with multidisciplinary and post-acute care teams to secure timely and appropriate transitions to the next level of care.
- Develop discharge plans that meet patients' continuing care needs and ensure that the medical record reflects education provided, coordination of services, referrals made, and authorizations obtained.
- Participate actively on committees, workgroups, and meetings to identify and refer quality issues for review to the Quality Management Program.
- 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 multidisciplinary team members 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.
- BSN or BSN in progress and/or willingness to acquire within 3 years of hire or transfer into the position; 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.
- Moderate to expert computer skills.
- Familiarity 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.
- Master's degree.
- Care Management, CCMA, or ACMA certification strongly preferred.
