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
Apply for the CARE COORDINATOR, CARE MANAGEMENT - PER DIEM role at JFK Johnson Rehabilitation Institute, Edison, New Jersey.
Overview The Care Coordinator 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 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 team members.
Facilitate communication and coordination between health‑care team members and involve the patient and family in decision making to minimize fragmentation, manage resources, and remove barriers.
Maintain current information of community resources and refer patients to appropriate resources. Consult with community agencies to identify potential resources to support patients and families.
Work collaboratively with multidisciplinary and post‑acute teams to secure timely and appropriate transitions to the next level of care.
Develop a discharge plan in collaboration with patient and support persons, identifying goals that provide maximum benefit. Ensure the plan meets continuing care needs.
Document and communicate information to the multidisciplinary team to coordinate and maximize care. Ensure the medical record reflects education, coordination, referrals, and authorizations.
Participate actively on appropriate committees, workgroups, or meetings.
Identify and refer quality issues for review to the Quality Management Program.
Participate in multidisciplinary rounds, specific to assigned units, bringing forth issues that impact discharge and length of stay for timely discussion and resolution.
Perform reassessments and evaluate progress against care goals and plan of care, revising plan as needed. Ensure the medical record reflects reassessment at least weekly and on any change affecting the plan.
Provide patients and families with resources and discharge options. Educate regarding risks, benefits, and available health‑care benefits.
Provide appropriate CMS documents per regulatory guidelines (e.g., Important Message 4 to 48 hours prior to discharge, appeal and HINN notices).
Utilize social determinants of health screening tools during each intake assessment.
Collaborate with the multidisciplinary team to support crisis intervention, counseling, abuse/neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, and hospital throughput.
Refer to facilities and services as required: acute rehab, sub‑acute rehab, long‑term care, assisted living, adult day program, PASRR screening, EARC screening, home care, hospice, durable medical equipment, transport, dialysis, financial assistance, medication assistance, palliative care, boarding placement, mental health services, homelessness placement, substance abuse placement, child protection, adult protective services.
Maintain annual competencies and ensure training and continuing education on applicable platforms (Epic, Xsolis Cortex, BI, Google Suites).
Other duties and/or projects as assigned.
Adhere to HMH Organizational competencies and standards of behavior.
Qualifications
Education:
BSN or BSN in progress (or willing to acquire within 3 years) or Master’s Degree in Social Work.
Knowledge, Skills & Abilities:
Effective decision‑making, creativity in problem solving, influential leadership. Excellent verbal, written, and presentation skills. Moderate to expert computer skills. Familiarity with hospital, community, and utilization management resources. Proficient in Microsoft Office and/or Google Suite.
Licenses & Certifications:
NJ Licensed Registered Nurse, NJ Licensed Social Worker, or NJ Licensed Clinical Social Worker.
Preferred Certifications:
Care Management (CCMA or ACMA).
Compensation Minimum rate: $43.63 per hour.
EEO Statement HACKENSACK MERIDIAN HEALTH (HMH) 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, MARRIAGE STATUS, PHYSICAL OR MENTAL ABILITY, NATIONWIDE ORIGIN, ANCESTRY, DISABILITY, MARRIAGE STATUS, VALEUR INDUSTRIAL OR PROTECTION STATUS.
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Overview The Care Coordinator 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 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 team members.
Facilitate communication and coordination between health‑care team members and involve the patient and family in decision making to minimize fragmentation, manage resources, and remove barriers.
Maintain current information of community resources and refer patients to appropriate resources. Consult with community agencies to identify potential resources to support patients and families.
Work collaboratively with multidisciplinary and post‑acute teams to secure timely and appropriate transitions to the next level of care.
Develop a discharge plan in collaboration with patient and support persons, identifying goals that provide maximum benefit. Ensure the plan meets continuing care needs.
Document and communicate information to the multidisciplinary team to coordinate and maximize care. Ensure the medical record reflects education, coordination, referrals, and authorizations.
Participate actively on appropriate committees, workgroups, or meetings.
Identify and refer quality issues for review to the Quality Management Program.
Participate in multidisciplinary rounds, specific to assigned units, bringing forth issues that impact discharge and length of stay for timely discussion and resolution.
Perform reassessments and evaluate progress against care goals and plan of care, revising plan as needed. Ensure the medical record reflects reassessment at least weekly and on any change affecting the plan.
Provide patients and families with resources and discharge options. Educate regarding risks, benefits, and available health‑care benefits.
Provide appropriate CMS documents per regulatory guidelines (e.g., Important Message 4 to 48 hours prior to discharge, appeal and HINN notices).
Utilize social determinants of health screening tools during each intake assessment.
Collaborate with the multidisciplinary team to support crisis intervention, counseling, abuse/neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, and hospital throughput.
Refer to facilities and services as required: acute rehab, sub‑acute rehab, long‑term care, assisted living, adult day program, PASRR screening, EARC screening, home care, hospice, durable medical equipment, transport, dialysis, financial assistance, medication assistance, palliative care, boarding placement, mental health services, homelessness placement, substance abuse placement, child protection, adult protective services.
Maintain annual competencies and ensure training and continuing education on applicable platforms (Epic, Xsolis Cortex, BI, Google Suites).
Other duties and/or projects as assigned.
Adhere to HMH Organizational competencies and standards of behavior.
Qualifications
Education:
BSN or BSN in progress (or willing to acquire within 3 years) or Master’s Degree in Social Work.
Knowledge, Skills & Abilities:
Effective decision‑making, creativity in problem solving, influential leadership. Excellent verbal, written, and presentation skills. Moderate to expert computer skills. Familiarity with hospital, community, and utilization management resources. Proficient in Microsoft Office and/or Google Suite.
Licenses & Certifications:
NJ Licensed Registered Nurse, NJ Licensed Social Worker, or NJ Licensed Clinical Social Worker.
Preferred Certifications:
Care Management (CCMA or ACMA).
Compensation Minimum rate: $43.63 per hour.
EEO Statement HACKENSACK MERIDIAN HEALTH (HMH) 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, MARRIAGE STATUS, PHYSICAL OR MENTAL ABILITY, NATIONWIDE ORIGIN, ANCESTRY, DISABILITY, MARRIAGE STATUS, VALEUR INDUSTRIAL OR PROTECTION STATUS.
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