What are the responsibilities and job description for the CARE COORDINATOR, CARE MANAGEMENT - PER DIEM position at JFK Johnson Rehabilitation Institute?
Care Coordinator, Care Management - Per Diem
SOUTHERN OCEAN MEDICAL CENTER Manahawkin, New Jersey
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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 Per Diem 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 Per Diem at Hackensack Meridian Health includes:
Education, Knowledge, Skills and Abilities Required:
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, pregnancy, breastfeeding, genetic information, refusal to submit to a genetic test or make available to an employer the results of a genetic test, atypical hereditary cellular or blood trait, national origin, nationality, ancestry, disability, marital status, liability for military service, or status as a protected veteran.
Our Network
Hackensack Meridian Health (HMH) is a Mandatory Influenza Vaccination Facility
As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.
Apply
Share
See the area you’ll be working in and get an idea of what your daily routine around the office can be like. Learn More
Awards We’ve Received
2023
US News & World Report 2023
US News & World Report 2023
US News & World Report 2023
2023
2023 & 2022 Magnet Designations
for 9 HMH Institutions
2022
Newsweek 2022 Best Hospitals USA
Newsweek 2022 America’s Best Addiction Treatment Centers
Blake Recovery Center at Carrier Clinic - #2
2023
Diversity Inc. 2023
Top Hospital and Health Systems
2022
Becker’s Hospital Review 2022
At Hackensack Meridian Health, we help our patients live better, healthier lives – and we help one another succeed. Here, competitive benefits are just the beginning. It’s also about how our team members support one another and how we show up for our community. Together, we’re ready to transform health care and advance our mission to serve as a leader of positive change.
Join us and let’s keep getting better together.
STAY CONNECTED
From roles that are right for you to new opportunities, join our talent community and stay up to date with job openings and more.
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SOUTHERN OCEAN MEDICAL CENTER Manahawkin, New Jersey
Apply
- Requisition # 2024-146247
- ShiftDay
- StatusPer Diem
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 Per Diem 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 Per Diem 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:
- 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.
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.
- Master's degree.
- NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker.
- Care Management, CCMA or ACMA certification strongly preferred.
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, pregnancy, breastfeeding, genetic information, refusal to submit to a genetic test or make available to an employer the results of a genetic test, atypical hereditary cellular or blood trait, national origin, nationality, ancestry, disability, marital status, liability for military service, or status as a protected veteran.
Our Network
Hackensack Meridian Health (HMH) is a Mandatory Influenza Vaccination Facility
As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.
Apply
Share
- X
- LinkedIn
See the area you’ll be working in and get an idea of what your daily routine around the office can be like. Learn More
Awards We’ve Received
2023
US News & World Report 2023
- HUMC - #1 Hospital in NJ & #5 in NY Metro Area
US News & World Report 2023
- Joseph M. Sanzari Children’s Hospital - #1 Children’s Hospital in NJ
US News & World Report 2023
- JSUMC - #6 Hospital in NJ
2023
2023 & 2022 Magnet Designations
for 9 HMH Institutions
2022
Newsweek 2022 Best Hospitals USA
- HUMC - #57
Newsweek 2022 America’s Best Addiction Treatment Centers
Blake Recovery Center at Carrier Clinic - #2
2023
Diversity Inc. 2023
Top Hospital and Health Systems
2022
Becker’s Hospital Review 2022
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At Hackensack Meridian Health, we help our patients live better, healthier lives – and we help one another succeed. Here, competitive benefits are just the beginning. It’s also about how our team members support one another and how we show up for our community. Together, we’re ready to transform health care and advance our mission to serve as a leader of positive change.
Join us and let’s keep getting better together.
STAY CONNECTED
From roles that are right for you to new opportunities, join our talent community and stay up to date with job openings and more.
SIGN UP
