JFK Johnson Rehabilitation Institute
CARE COORDINATOR, CARE MANAGEMENT - PER DIEM
JFK Johnson Rehabilitation Institute, Holmdel, New Jersey, United States
Overview
CARE COORDINATOR, CARE MANAGEMENT - PER DIEM. The CARE COORDINATOR, CARE MANAGEMENT role at JFK Johnson Rehabilitation Institute supports the clinical progression of patient treatment and discharge planning. The coordinator is responsible for a designated patient caseload, assessing and facilitating care with patients, families, and the multidisciplinary team to meet treatment goals, expected length of stay, and appropriate next levels of care. Oversees interfacility transitions and handoffs between acute and post-acute services. Responsibilities
Assess patients by screening for potential discharge needs; meet directly with patient/family to assess needs and develop an individualized care plan in collaboration with the physician and health care team. Facilitate communication and coordination among health care team members; involve patient and family in decision making to minimize fragmentation, manage resources, and remove barriers to the plan of care. Maintain current information on community resources; refer patients to appropriate resources; consult with community agencies to identify resources supporting patients and families. Work collaboratively with multidisciplinary and post-acute care teams to secure timely transitions to the next level of care. Develop discharge plans with patient and support persons, identifying goals that maximize benefit and ensure continuing care needs are met. Document and communicate information to the multidisciplinary team; ensure medical records reflect education, coordination of services, referrals, and authorizations. Participate actively on committees, workgroups, or meetings; identify and refer quality issues for review to the Quality Management Program. Participate in multidisciplinary rounds; raise issues impacting discharge and length of stay for discussion and resolution. Reassess progress against goals; revise plans as needed; ensure medical records reflect weekly reassessments and any changes in medical condition. Provide patients and families with resources and discharge options; educate on risks/benefits of options and available health care benefits. Provide CMS documents to patients and families per regulatory guidelines (eg., Important Message within 4 to 48 hours prior to discharge, and related notices). Utilize social determinants of health screening tools during intake assessments. Collaborate with the team to support crisis intervention, counseling, referrals, abuse/neglect reporting, guardianship, psychosocial assessments, and hospital throughput. Make referrals as required to facilities and services such as acute rehabilitation, sub-acute rehab, long-term care, assisted living, adult day programs, PASRR screening, EAR C screening, home care, hospice, DME, transport, dialysis, financial assistance, medication assistance, palliative care, boarding home placement, mental health services, homelessness placement, substance abuse services, and applicable protective services. Maintain annual competencies and ensure training and continuing education for the team in applicable platforms (Epic, Xsolis Cortex, BI, Google Suites). Adhere to organizational competencies and standards of behavior; perform other duties and/or projects as assigned. Qualifications
Education, Knowledge, Skills and Abilities Required: BSN or BSN in progress and/or willingness to acquire within 3 years of hire; or Master’s Degree in Social Work. Effective decision-making, creative problem-solving, and influential leadership skills. Excellent verbal, written, and presentation skills. Moderate to expert computer skills; familiar with hospital and community resources, and utilization management. Proficient with Microsoft Office and/or Google Suite. Education, Knowledge, Skills And Abilities Preferred Master's degree. Licenses And Certifications Required New Jersey Licensed Registered Nurse or New Jersey Licensed Social Worker or New Jersey Licensed Clinical Social Worker. Licenses And Certifications Preferred Care Management, CCMA or ACMA certification strongly preferred. Compensation and Benefits
Minimum rate of $43.63 hourly. Hackensack Meridian Health is committed to pay equity and transparency. The posted rate is a reasonable good faith estimate of the minimum base pay at the time of posting and may not reflect the full value of the total rewards package. The starting rate is for informational purposes and may differ at the time of offer depending on factors such as labor market data, experience, education, certifications, skills, location, internal equity, and budget. In addition to compensation, HMH offers a comprehensive benefits package including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits. HMH is an Equal Opportunity Employer and considers all qualified applicants without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, genetic information, disability, marital status, or status as a protected veteran. Our network and community commitments: Hackensack Meridian Health is a Mandatory Influenza Vaccination Facility. Apply to join our team and stay connected with job openings and opportunities across the network.
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CARE COORDINATOR, CARE MANAGEMENT - PER DIEM. The CARE COORDINATOR, CARE MANAGEMENT role at JFK Johnson Rehabilitation Institute supports the clinical progression of patient treatment and discharge planning. The coordinator is responsible for a designated patient caseload, assessing and facilitating care with patients, families, and the multidisciplinary team to meet treatment goals, expected length of stay, and appropriate next levels of care. Oversees interfacility transitions and handoffs between acute and post-acute services. Responsibilities
Assess patients by screening for potential discharge needs; meet directly with patient/family to assess needs and develop an individualized care plan in collaboration with the physician and health care team. Facilitate communication and coordination among health care team members; involve patient and family in decision making to minimize fragmentation, manage resources, and remove barriers to the plan of care. Maintain current information on community resources; refer patients to appropriate resources; consult with community agencies to identify resources supporting patients and families. Work collaboratively with multidisciplinary and post-acute care teams to secure timely transitions to the next level of care. Develop discharge plans with patient and support persons, identifying goals that maximize benefit and ensure continuing care needs are met. Document and communicate information to the multidisciplinary team; ensure medical records reflect education, coordination of services, referrals, and authorizations. Participate actively on committees, workgroups, or meetings; identify and refer quality issues for review to the Quality Management Program. Participate in multidisciplinary rounds; raise issues impacting discharge and length of stay for discussion and resolution. Reassess progress against goals; revise plans as needed; ensure medical records reflect weekly reassessments and any changes in medical condition. Provide patients and families with resources and discharge options; educate on risks/benefits of options and available health care benefits. Provide CMS documents to patients and families per regulatory guidelines (eg., Important Message within 4 to 48 hours prior to discharge, and related notices). Utilize social determinants of health screening tools during intake assessments. Collaborate with the team to support crisis intervention, counseling, referrals, abuse/neglect reporting, guardianship, psychosocial assessments, and hospital throughput. Make referrals as required to facilities and services such as acute rehabilitation, sub-acute rehab, long-term care, assisted living, adult day programs, PASRR screening, EAR C screening, home care, hospice, DME, transport, dialysis, financial assistance, medication assistance, palliative care, boarding home placement, mental health services, homelessness placement, substance abuse services, and applicable protective services. Maintain annual competencies and ensure training and continuing education for the team in applicable platforms (Epic, Xsolis Cortex, BI, Google Suites). Adhere to organizational competencies and standards of behavior; perform other duties and/or projects as assigned. Qualifications
Education, Knowledge, Skills and Abilities Required: BSN or BSN in progress and/or willingness to acquire within 3 years of hire; or Master’s Degree in Social Work. Effective decision-making, creative problem-solving, and influential leadership skills. Excellent verbal, written, and presentation skills. Moderate to expert computer skills; familiar with hospital and community resources, and utilization management. Proficient with Microsoft Office and/or Google Suite. Education, Knowledge, Skills And Abilities Preferred Master's degree. Licenses And Certifications Required New Jersey Licensed Registered Nurse or New Jersey Licensed Social Worker or New Jersey Licensed Clinical Social Worker. Licenses And Certifications Preferred Care Management, CCMA or ACMA certification strongly preferred. Compensation and Benefits
Minimum rate of $43.63 hourly. Hackensack Meridian Health is committed to pay equity and transparency. The posted rate is a reasonable good faith estimate of the minimum base pay at the time of posting and may not reflect the full value of the total rewards package. The starting rate is for informational purposes and may differ at the time of offer depending on factors such as labor market data, experience, education, certifications, skills, location, internal equity, and budget. In addition to compensation, HMH offers a comprehensive benefits package including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits. HMH is an Equal Opportunity Employer and considers all qualified applicants without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, genetic information, disability, marital status, or status as a protected veteran. Our network and community commitments: Hackensack Meridian Health is a Mandatory Influenza Vaccination Facility. Apply to join our team and stay connected with job openings and opportunities across the network.
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