How have you impacted someone’s life today? At Hackensack Meridian Health our healthcare teams are focused on changing the lives of our patients by providing the highest level of care each and every day.  From our hospitals, rehab centers and occupational health teams to our long-term care centers and at-home care capabilities, our complete spectrum of services will allow you to apply your skills in multiple settings while building your career all within New Jersey’s premier healthcare system.

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.

A day in the life of a Care Coordinator, Care Manager 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, bringing 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 

• Bachelor's Degree in Nursing or Master's Degree in Social Work
• NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker
• Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills
• Excellent verbal, written and presentation skills
• Familiar with hospital resources, community resources, and utilization management
• Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms