Care Coordinator, Care Management

Care Coordinator, Care Management – RARITAN BAY MEDICAL CENTER- OLD BRIDGE, Old Bridge, New Jersey

Apply
Requisition # | Shift: Day | Status:
Full Time with Benefits

Our team members are the heart of what makes us better. Here at Hackensack Meridian Health we help our patients live better, healthier lives and support one another. We keep improving to transform healthcare and lead positive change.

• 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 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 appropriate for the patient's care. Consults with community agencies and committees to identify additional resources.
• 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 and ensuring the plan meets the patient's continuing care needs.
• Documents and communicates information to the multidisciplinary team to coordinate and maximize care, ensuring the medical record reflects education, coordination of services, referrals made, and authorizations obtained.
• Participates actively on appropriate committees, work groups, or meetings.
• Identifies and refers quality issues for review to the Quality Management Program.
• Participates in multidisciplinary rounds specific to assigned units, bringing forth issues impacting discharge and length of stay for timely discussion and resolution.
• Performs appropriate reassessments and evaluates progress against care goals, revising the plan as needed and ensuring the medical record reflects reassessment at least weekly and upon any change in medical condition.
• Provides patients and families with resources and discharge options, educating regarding risks and benefits and available health care benefits.
• Provides appropriate CMS documents to the patient and family/support person as per regulatory guidelines (e.g., 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 functions such as crisis intervention, counseling support and referrals, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, and hospital throughput.
• Referrals should be made to the following as required/needed:
  • Acute rehabilitation facilities
  • Sub‑acute rehabilitation facilities
  • Long Term Care facilities
  • Assisted Living facilities
  • Adult day program
  • Level 1/Level 2 PASRR screening
  • EARC screening
  • Home Care
  • Hospice
  • Durable medical equipment
  • Transport
  • Dialysis
  • Financial assistance
  • Medication assistance
  • Palliative Care
  • Boarding home placement
  • Mental health services
  • Homelessness placement
  • Substance abuse placement
  • Division of Child Protection and Permanency
  • Adult Protective Services
• Maintains annual competencies and ensures training and continuing education of the team in applicable platforms (Epic, Xsolis Cortex, BI, Google Suites).
• Other duties and/or projects as assigned.
• Adheres to HMH Organizational competencies and standards of behavior.

• BSN or BSN in progress and/or willing to acquire within 3 years of hire or transfer into the position; or Master’s Degree in Social Work.
• Effective decision‑making skills, creativity in problem‑solving, and influential leadership skills.
• Excellent verbal, written and presentation skills.
• Moderate to expert computer skills.
• Familiar with hospital…