Hackensack Meridian Health
Care Coordinator, Care Management (LSW/LCSW or RN) - Per Diem
Hackensack Meridian Health, Laurelton, New Jersey, United States
Care Coordinator, Care Management (LSW/LCSW or RN) - Per Diem
Join our team as a
Care Coordinator, Care Management (LSW/LCSW or RN) - Per Diem
at
Hackensack Meridian Health . Description 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. With a culture rooted in connection and collaboration, our employees are valued team members. We offer competitive benefits, a supportive environment, and a commitment to community service. Together, we continue to improve, advancing our mission to transform healthcare and lead positive change. The
Care Coordinator, Care Management
is part of the healthcare team responsible for coordinating, communicating, and facilitating the clinical progression of patients' treatment and discharge plans. They manage a designated patient caseload, assessing, planning, and collaborating with patients, families, and the multidisciplinary team to meet treatment goals, optimize length of stay, and arrange appropriate next-level care. They oversee interfacility transitions and handoffs between acute and post-acute services. Responsibilities Assess patients by screening for potential discharge needs, regardless of race, age, sex, religion, diagnosis, or ability to pay. Meet directly with patients and families to develop individualized care plans in collaboration with physicians and healthcare team members. Facilitate communication and coordination among healthcare team members, involving patients and families in decision-making to minimize fragmentation, manage resources, and remove barriers. Maintain current knowledge of community resources and refer patients to appropriate services. Collaborate with community agencies to identify additional resources supporting patients and families. Work collaboratively with multidisciplinary and post-acute care teams to ensure timely and appropriate transitions to the next level of care. Develop discharge plans with patients and support persons, setting goals that maximize benefits and meet ongoing care needs. Document and communicate relevant information to the multidisciplinary team, ensuring the medical record reflects education, referrals, authorizations, and coordination efforts. Participate in committees, workgroups, and meetings as appropriate. Identify and refer quality issues to the Quality Management Program. Participate in multidisciplinary rounds, addressing issues impacting discharge and length of stay. Reassess and evaluate patient progress, revising plans as needed, with documentation reflecting weekly and condition-based updates. Provide patients and families with resources, discharge options, and education on risks and benefits. Distribute CMS documents as per regulatory guidelines (e.g., Important Message, appeal notices). Use social determinants of health screening tools during assessments. Collaborate on functions such as crisis intervention, counseling, reporting, guardianship, psychosocial assessments, and hospital throughput. Make referrals to various facilities and services, including rehabilitation, long-term care, assisted living, home care, hospice, equipment, transportation, and social services. Maintain annual competencies and ensure ongoing training in platforms like Epic, Xsolis Cortex, BI, and Google Suites. Perform other duties or projects as assigned, adhering to organizational standards and behaviors. Qualifications Required: BSN or in progress with a plan to acquire within 3 years, or a Master’s Degree in Social Work. Effective decision-making, problem-solving, and leadership skills. Excellent verbal, written, and presentation skills. Moderate to advanced computer skills. Knowledge of hospital and community resources, utilization management. Preferred: Master’s degree. Licenses and Certifications Required: NJ Licensed Registered Nurse, Licensed Social Worker, or Licensed Clinical Social Worker. Preferred: Care Management, CCMA, or ACMA certification.
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Join our team as a
Care Coordinator, Care Management (LSW/LCSW or RN) - Per Diem
at
Hackensack Meridian Health . Description 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. With a culture rooted in connection and collaboration, our employees are valued team members. We offer competitive benefits, a supportive environment, and a commitment to community service. Together, we continue to improve, advancing our mission to transform healthcare and lead positive change. The
Care Coordinator, Care Management
is part of the healthcare team responsible for coordinating, communicating, and facilitating the clinical progression of patients' treatment and discharge plans. They manage a designated patient caseload, assessing, planning, and collaborating with patients, families, and the multidisciplinary team to meet treatment goals, optimize length of stay, and arrange appropriate next-level care. They oversee interfacility transitions and handoffs between acute and post-acute services. Responsibilities Assess patients by screening for potential discharge needs, regardless of race, age, sex, religion, diagnosis, or ability to pay. Meet directly with patients and families to develop individualized care plans in collaboration with physicians and healthcare team members. Facilitate communication and coordination among healthcare team members, involving patients and families in decision-making to minimize fragmentation, manage resources, and remove barriers. Maintain current knowledge of community resources and refer patients to appropriate services. Collaborate with community agencies to identify additional resources supporting patients and families. Work collaboratively with multidisciplinary and post-acute care teams to ensure timely and appropriate transitions to the next level of care. Develop discharge plans with patients and support persons, setting goals that maximize benefits and meet ongoing care needs. Document and communicate relevant information to the multidisciplinary team, ensuring the medical record reflects education, referrals, authorizations, and coordination efforts. Participate in committees, workgroups, and meetings as appropriate. Identify and refer quality issues to the Quality Management Program. Participate in multidisciplinary rounds, addressing issues impacting discharge and length of stay. Reassess and evaluate patient progress, revising plans as needed, with documentation reflecting weekly and condition-based updates. Provide patients and families with resources, discharge options, and education on risks and benefits. Distribute CMS documents as per regulatory guidelines (e.g., Important Message, appeal notices). Use social determinants of health screening tools during assessments. Collaborate on functions such as crisis intervention, counseling, reporting, guardianship, psychosocial assessments, and hospital throughput. Make referrals to various facilities and services, including rehabilitation, long-term care, assisted living, home care, hospice, equipment, transportation, and social services. Maintain annual competencies and ensure ongoing training in platforms like Epic, Xsolis Cortex, BI, and Google Suites. Perform other duties or projects as assigned, adhering to organizational standards and behaviors. Qualifications Required: BSN or in progress with a plan to acquire within 3 years, or a Master’s Degree in Social Work. Effective decision-making, problem-solving, and leadership skills. Excellent verbal, written, and presentation skills. Moderate to advanced computer skills. Knowledge of hospital and community resources, utilization management. Preferred: Master’s degree. Licenses and Certifications Required: NJ Licensed Registered Nurse, Licensed Social Worker, or Licensed Clinical Social Worker. Preferred: Care Management, CCMA, or ACMA certification.
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