Care Management Coordinator: Discharge & Transitions

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 of positive 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 includes: 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. (Epic, Xsolis Cortex, BI, Google Suites) Other duties and/or projects as assigned. Adheres to HMH Organizational competencies and standards of behavior. 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. Familiar with hospital resources, community resources, and utilization management. Excellent written and verbal communication skills. Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms. Education, Knowledge, Skills and Abilities Preferred: Master's degree. 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. Starting Minimum Rate Minimum rate of $97,011.20 Annually Job Posting Disclosure HMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market-competitive total rewards package. The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non-discriminatory factors, including but not limited to: Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness. Experience: Years of relevant work experience. Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training. Skills: Demonstrated proficiency in relevant skills and competencies. Geographic Location: Cost of living and market rates for the specific location. Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization. Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered. Some jobs may also be eligible for performance-based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts. In addition to our compensation for full-time and part-time (20+ hours/week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits. #J-18808-Ljbffr Hackensack Meridian Health