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Job Information
Hackensack Meridian Health Care Coordinator - Care Management - F/T - Days in Perth Amboy, New Jersey
Overview
Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are
team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader ofpositive change.
The Care Coordinator, Care Management is a member of the healthcare team and is responsible for coordinating, communicating, and facilitating the clinical progression of the patient's treatment and discharge plan. Accountable for a designated patient caseload; assesses, plans, and facilitates with patients, families and the multidisciplinary team to meet treatment goals, expected length of stay, and arrange for the appropriate next level of care. Oversees interfacility transitions and handoff between acute and post-acute services.
Responsibilities
A day in the life of a Care Coordinator, Care Management at Hackensack Meridian Health may include:
Assesses patients by screening for potential discharge needs regardless of race, age, sex, religion, diagnosis and ability to pay. Meets directly with patient/family to assess needs and develop an individualized care plan in collaboration with the physician and other members of the health care team. Facilitates communication and coordination between members of the health care team and involves the patient and family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the plan of care
Maintains current information of community resources and refers patients to those community resources appropriate for the patient's care. Consults with other community agencies and committees to identify potential resources to support patients and their families
Works 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
Develops a discharge plan, in collaboration with the patient and support persons, identifying goals that will provide maximum benefit for each patient. Ensures that the discharge plan meets the continuing care needs of the patient
Documents and communicates information to the multidisciplinary team in order to coordinate and maximize care. Ensures that the medical record reflects the education provided, coordination of services, referrals made and authorizations obtained
Participates actively on appropriate committees, workgroups, and or meetings
Identifies and refers quality issues for review to the Quality Management Program
Participates in multidisciplinary rounds, specific to assigned units. Brings forth issues which impact on discharge as well as length of stay in a timely manner, for discussion and resolution
Performs appropriate reassessments and evaluates progress against care goals and the plan of care and revises plan, as needed. Ensures that the medical record reflects reassessment of the discharge plan at least weekly and upon any change in medical condition affecting the plan
Provides patients and families with resources and discharge options. Educates regarding the risks and benefits of discharge options and any available health care benefits
Provides appropriate CMS documents to the patient and family/support person as per regulatory guidelines (ie., Important Message 4 to 48 hours prior to discharge, appeal and HINN notices)
Utilizes social determinants of health screening tools and resources during each intake assessment
Collaborates 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: a. Acute rehabilitation facilities b. Sub- Acute rehabilitation facilities c. Long Term Care facilities d. Assisted Living facilities e. Adult day program f. Level 1/Level 2 PASRR screening g. EARC screening h. Home Care i. Hospice j. Durable medical equipment k. Transport l. Dialysis m. Financial assistance n. Medication assistance o. Palliative Care p. Boarding home placement q. Mental health services r. Homelessness placement s. Substance abuse placement t. Division of Child Protection and Permanency u. Adult Protective Services
Maintains annual competencies and ensures 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,proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.
Familiar with hospital resources, community resources, and utilization management
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.
Job ID 2024-143399
Department PA-CASE MGMT
Site Raritan Bay Medical Center
Job Location US-NJ-Perth Amboy
Position Type Full Time with Benefits
Standard Hours Per Week 40
Shift Day
Shift Hours 7 a.m. - 7 p.m.
Weekend Work Every Fourth Weekend
On Call Work No On-Call Required
Holiday Work As Needed