JFK Johnson Rehabilitation Institute
CARE COORDINATOR, CARE MANAGEMENT - PER DIEM
JFK Johnson Rehabilitation Institute, Edison, New Jersey, us, 08818
CARE COORDINATOR, CARE MANAGEMENT - PER DIEM
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Care Coordinator, Care Management – Per Diem JFK University Medical Center, Edison, 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 support one another to succeed. The Care Coordinator, Care Management is a member of the healthcare team 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
Assess patients by screening for potential discharge needs and develop individualized care plans with physician and team.
Facilitate communication and coordination among the care team, involving patients and families in decision making.
Maintain up‑to‑date community resource information and refer patients to appropriate resources.
Work collaboratively with multidisciplinary and post‑acute teams to secure timely transitions.
Develop discharge plans that meet continuing care needs and document plans in the medical record.
Participate in committees, workgroups, and meetings as required.
Identify and refer quality issues to the Quality Management Program.
Participate in multidisciplinary rounds, addressing discharge and length‑of‑stay issues promptly.
Perform reassessments and update care plans as needed, documenting reassessments weekly or upon changes.
Provide patients and families with resources and discharge options, including education on risks and benefits.
Provide required CMS documents and ICR notices as per regulatory guidelines.
Utilize social determinants of health screening tools during intake assessments.
Collaborate on crisis intervention, counseling support, abuse/neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, and hospital throughput.
Refer patients to appropriate facilities and services: acute rehab, sub‑acute rehab, long‑term care, assisted living, adult day program, PASRR/EARC screening, home care, hospice, durable medical equipment, transport, dialysis, financial and medication assistance, palliative care, boarding homes, mental health services, homelessness placement, substance abuse placement, child protection, and adult protective services.
Maintain annual competencies and ensure team training and continuing education on applicable platforms (Epic, Xsolis Cortex, BI, Google Suite).
Perform other duties or projects as assigned.
Adhere to HMH Organizational competencies and standards of behavior.
Qualifications
Education and Experience
BSN or BSN in progress and willing to complete within 3 years of hire; or Master’s Degree in Social Work.
NJ Licensed Registered Nurse, NJ Licensed Social Worker, or NJ Licensed Clinical Social Worker.
Knowledge, Skills, and Abilities
Effective decision‑making and problem‑solving skills.
Excellent verbal, written, and presentation skills.
Moderate to expert computer skills, including Microsoft Office and Google Suite.
Familiarity with hospital resources, community resources, and utilization management.
Proficient in Epic, Xsolis Cortex, BI, and other relevant platforms.
Preferred
Master’s degree.
Care Management, CCMA, or ACMA certification.
Compensation Minimum rate of $43.63 hourly. HMH offers a comprehensive benefits package including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.
Equal Opportunity Employer
Hackensack Meridian Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, breastfeeding, genetic information, or protected veteran status.
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Care Coordinator, Care Management – Per Diem JFK University Medical Center, Edison, 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 support one another to succeed. The Care Coordinator, Care Management is a member of the healthcare team 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
Assess patients by screening for potential discharge needs and develop individualized care plans with physician and team.
Facilitate communication and coordination among the care team, involving patients and families in decision making.
Maintain up‑to‑date community resource information and refer patients to appropriate resources.
Work collaboratively with multidisciplinary and post‑acute teams to secure timely transitions.
Develop discharge plans that meet continuing care needs and document plans in the medical record.
Participate in committees, workgroups, and meetings as required.
Identify and refer quality issues to the Quality Management Program.
Participate in multidisciplinary rounds, addressing discharge and length‑of‑stay issues promptly.
Perform reassessments and update care plans as needed, documenting reassessments weekly or upon changes.
Provide patients and families with resources and discharge options, including education on risks and benefits.
Provide required CMS documents and ICR notices as per regulatory guidelines.
Utilize social determinants of health screening tools during intake assessments.
Collaborate on crisis intervention, counseling support, abuse/neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, and hospital throughput.
Refer patients to appropriate facilities and services: acute rehab, sub‑acute rehab, long‑term care, assisted living, adult day program, PASRR/EARC screening, home care, hospice, durable medical equipment, transport, dialysis, financial and medication assistance, palliative care, boarding homes, mental health services, homelessness placement, substance abuse placement, child protection, and adult protective services.
Maintain annual competencies and ensure team training and continuing education on applicable platforms (Epic, Xsolis Cortex, BI, Google Suite).
Perform other duties or projects as assigned.
Adhere to HMH Organizational competencies and standards of behavior.
Qualifications
Education and Experience
BSN or BSN in progress and willing to complete within 3 years of hire; or Master’s Degree in Social Work.
NJ Licensed Registered Nurse, NJ Licensed Social Worker, or NJ Licensed Clinical Social Worker.
Knowledge, Skills, and Abilities
Effective decision‑making and problem‑solving skills.
Excellent verbal, written, and presentation skills.
Moderate to expert computer skills, including Microsoft Office and Google Suite.
Familiarity with hospital resources, community resources, and utilization management.
Proficient in Epic, Xsolis Cortex, BI, and other relevant platforms.
Preferred
Master’s degree.
Care Management, CCMA, or ACMA certification.
Compensation Minimum rate of $43.63 hourly. HMH offers a comprehensive benefits package including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.
Equal Opportunity Employer
Hackensack Meridian Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, breastfeeding, genetic information, or protected veteran status.
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