Care Coordinator, Care Management

Care Coordinator, Care Management

JFK Johnson Rehabilitation Institute, Edison, New Jersey

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. The coordinator is 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, including interfacility transitions and handoff between acute and post‑acute services.

• 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 on community resources and refers patients to those 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 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 the medical record reflects the education provided, coordination of services, referrals made and authorizations obtained.
• Participates actively on appropriate committees, work groups, 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 and 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; 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.
• 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 (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 crisis intervention, counseling support and referrals, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management and hospital throughput.
• Referrals to include acute rehabilitation facilities, sub‑acute rehabilitation facilities, long‑term care facilities, assisted living facilities, adult day program, PASRR screening, EARC screening, home…