Care Coordinator - Care Management - F/T - Days

Perth Amboy, NJ, United States

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 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 ofpositive change.

The Care Coordinator, Care Management is a member of the healthcare team and is 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

A day in the life of a Care Coordinator, Care Management at Hackensack Meridian Health may include:

Assesses patients by screening for potential discharge needs regardless of race, age, sex, religion, diagnosis and ability to pay. Meets directly with patient/family to assess needs and develop an individualized care plan in collaboration with the physician and other members of the health care team. Facilitates communication and coordination between members of the health care team and involves the patient and family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the plan of care

Maintains current information of community resources and refers patients to those community resources appropriate for the patient's care. Consults with other community agencies and committees to identify potential resources to support patients and their families

Works collaboratively with all team members of the multidisciplinary and post acute care teams to secure timely and appropriate transitions to the next level of care

Develops a discharge plan, in collaboration with the patient and support persons, identifying goals that will provide maximum benefit for each patient. Ensures that the discharge plan meets the continuing care needs of the patient

Documents and communicates information to the multidisciplinary team in order to coordinate and maximize care. Ensures that the medical record reflects the education provided, coordination of services, referrals made and authorizations obtained

Participates actively on appropriate committees, workgroups, and or meetings

Identifies and refers quality issues for review to the Quality Management Program

Participates in multidisciplinary rounds, specific to assigned units. Brings forth issues which impact on discharge as well as length of stay in a timely manner, for discussion and resolution

Performs appropriate reassessments and evaluates progress against care goals and the plan of care and revises plan, as needed. Ensures that the medical record reflects reassessment of the discharge plan at least weekly and upon any change in medical condition affecting the plan

Provides patients and families with resources and discharge options. Educates regarding the risks and benefits of discharge options and any available health care benefits

Provides appropriate CMS documents to the patient and family/support person as per regulatory guidelines (ie., Important Message 4 to 48 hours prior to discharge, appeal and HINN notices)

Utilizes social determinants of health screening tools and resources during each intake assessment

Collaborates with all members of the multidisciplinary team to support the following functions; crisis intervention, counseling support and referrals, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, hospital throughput

Referrals should be made to the following as required/needed: a. Acute rehabilitation facilities b. Sub- Acute rehabilitation facilities c. Long Term Care facilities d. Assisted Living facilities e. Adult day program f. Level 1/Level 2 PASRR screening g. EARC screening h. Home Care i. Hospice j. Durable medical equipment k. Transport l. Dialysis m. Financial assistance n. Medication assistance o. Palliative Care p. Boarding home placement q. Mental health services r. Homelessness placement s. Substance abuse placement t. Division of Child Protection and Permanency u. Adult Protective Services

Maintains annual competencies and ensures training and continuing education of the team in applicable platforms

Qualifications

Education, Knowledge, Skills and Abilities Required:

BSN or BSN in progress and/or willing to acquire within 3 years of hire or transfer into the position; or Masters Degree in Social Work

Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills

Excellent verbal, written and presentation skills

Moderate to expert computer skills,proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.

Familiar with hospital resources, community resources, and utilization management

Licenses and Certifications Required:

NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker

Licenses and Certifications Preferred:

Care Management, CCMA or ACMA certification strongly preferred.

Job ID 2024-143399

Department PA-CASE MGMT

Site Raritan Bay Medical Center

Job Location US-NJ-Perth Amboy

Position Type Full Time with Benefits

Standard Hours Per Week 40

Shift Day

Shift Hours 7 a.m. - 7 p.m.

Weekend Work Every Fourth Weekend

On Call Work No On-Call Required

Holiday Work As Needed