Hackensack Meridian Health
Care Coordinator, Care Management (LSW/LCSW or RN)
Hackensack Meridian Health, Holmdel, New Jersey, United States
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Care Coordinator, Care Management
role at
Hackensack Meridian Health
2 weeks ago Be among the first 25 applicants
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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 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 of positive change.
Role Overview 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. They are accountable for a designated patient caseload, assessing, planning, and facilitating with patients, families, and the multidisciplinary team to meet treatment goals, expected length of stay, and arrange for the appropriate next level of care. They oversee interfacility transitions and handoff between acute and post-acute services.
Responsibilities
Assess patients by screening for potential discharge needs regardless of race, age, sex, religion, diagnosis, and ability to pay. Meet directly with patient/family to assess needs and develop an individualized care plan in collaboration with the physician and other members of the healthcare team.
Facilitate communication and coordination among healthcare team members, involving patients and families in decision-making to minimize fragmentation of services, manage resources, and remove barriers to the care plan.
Maintain current information on community resources and refer patients to appropriate services. Collaborate with community agencies to identify additional resources supporting patients and families.
Work 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 to maximize benefit and meet continuing care needs.
Document and communicate relevant information to the multidisciplinary team, ensuring the medical record reflects education, referrals, and authorizations.
Participate actively in committees, workgroups, and meetings.
Identify and refer quality issues for review.
Participate in multidisciplinary rounds, addressing issues impacting discharge and length of stay.
Reassess and evaluate patient progress, revising plans as needed, and document these in the medical record.
Provide patients and families with resources, discharge options, and education on risks and benefits.
Provide CMS documents as per regulatory guidelines.
Utilize social determinants of health screening tools during assessments.
Collaborate on functions like crisis intervention, counseling, reporting, and guardianship.
Make referrals to various facilities and services as needed.
Maintain annual competencies and ensure team training and education.
Perform other duties as assigned, adhering to organizational standards.
Qualifications Required
BSN or BSN in progress, or Master’s Degree in Social Work.
Effective decision-making, problem-solving, and leadership skills.
Excellent verbal, written, and presentation skills.
Moderate to expert computer skills.
Knowledge of hospital and community resources, utilization management.
Proficient in Microsoft Office and Google Suite platforms.
Preferred
Master’s degree.
Licenses and Certifications
NJ Licensed Registered Nurse, Social Worker, or Clinical Social Worker (required).
Care Management, CCMA, or ACMA certification (preferred).
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!
#J-18808-Ljbffr
Care Coordinator, Care Management
role at
Hackensack Meridian Health
2 weeks ago Be among the first 25 applicants
Get AI-powered advice on this job and more exclusive features.
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 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 of positive change.
Role Overview 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. They are accountable for a designated patient caseload, assessing, planning, and facilitating with patients, families, and the multidisciplinary team to meet treatment goals, expected length of stay, and arrange for the appropriate next level of care. They oversee interfacility transitions and handoff between acute and post-acute services.
Responsibilities
Assess patients by screening for potential discharge needs regardless of race, age, sex, religion, diagnosis, and ability to pay. Meet directly with patient/family to assess needs and develop an individualized care plan in collaboration with the physician and other members of the healthcare team.
Facilitate communication and coordination among healthcare team members, involving patients and families in decision-making to minimize fragmentation of services, manage resources, and remove barriers to the care plan.
Maintain current information on community resources and refer patients to appropriate services. Collaborate with community agencies to identify additional resources supporting patients and families.
Work 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 to maximize benefit and meet continuing care needs.
Document and communicate relevant information to the multidisciplinary team, ensuring the medical record reflects education, referrals, and authorizations.
Participate actively in committees, workgroups, and meetings.
Identify and refer quality issues for review.
Participate in multidisciplinary rounds, addressing issues impacting discharge and length of stay.
Reassess and evaluate patient progress, revising plans as needed, and document these in the medical record.
Provide patients and families with resources, discharge options, and education on risks and benefits.
Provide CMS documents as per regulatory guidelines.
Utilize social determinants of health screening tools during assessments.
Collaborate on functions like crisis intervention, counseling, reporting, and guardianship.
Make referrals to various facilities and services as needed.
Maintain annual competencies and ensure team training and education.
Perform other duties as assigned, adhering to organizational standards.
Qualifications Required
BSN or BSN in progress, or Master’s Degree in Social Work.
Effective decision-making, problem-solving, and leadership skills.
Excellent verbal, written, and presentation skills.
Moderate to expert computer skills.
Knowledge of hospital and community resources, utilization management.
Proficient in Microsoft Office and Google Suite platforms.
Preferred
Master’s degree.
Licenses and Certifications
NJ Licensed Registered Nurse, Social Worker, or Clinical Social Worker (required).
Care Management, CCMA, or ACMA certification (preferred).
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!
#J-18808-Ljbffr