Care Coordinator, Care Management

Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives, and help one another succeed. With a culture rooted in connection and collaboration, employees enjoy competitive benefits and support and a commitment to community.

As a member of the healthcare team, the Care Coordinator is responsible for coordinating, communicating, and facilitating the clinical progression of patients’ treatment and discharge plans. Accountable for a designated patient caseload, the Coordinator assesses, plans, and facilitates care alongside patients, families, and the multidisciplinary team to meet treatment goals and expected length of stay, and arranges for the appropriate next level of care.

They oversee interfacility transitions and handoffs between acute and post‑acute services.

• Assess patients by screening for potential discharge needs regardless of race, age, sex, religion, diagnosis, and ability to pay.
• Facilitate communication and coordination between healthcare team members and involve patients and families in decision‑making to minimize fragmentation of services, manage resources, and remove barriers to the plan of care.
• Maintain current information on community resources and refer patients appropriately.
• Consult with community agencies and committees to identify resources to support patients and families.
• Collaborate with multidisciplinary and post‑acute care teams to secure timely transitions.
• Develop a discharge plan in collaboration with patient and support persons, ensuring it meets continuing care needs.
• Document and communicate information to the multidisciplinary team in the medical record.
• Participate actively in committees, work groups, and meetings.
• Identify and refer quality issues to the Quality Management Program.
• Participate in multidisciplinary rounds specific to assigned units.
• Perform reassessments and evaluate progress, revising plans as needed.
• Provide patients and families with resources and discharge options; educate on risks and benefits.
• Provide appropriate CMS documents as per regulatory guidelines.
• Utilize social determinants of health screening tools during intake assessment.
• Collaborate with multidisciplinary team for crisis intervention, counseling support, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, and hospital throughput.
• Make referrals to a range of services (rehabilitation facilities, assisted living, adult day programs, 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, child protection services, adult protective services).
• Maintain annual competencies and ensure training and continued education of the team in applicable platforms (Epic, Xsolis Cortex, BI, Google Suites).
• Adhere to HMH organizational competencies and standards of behavior.
• Other duties or projects as assigned.

• BSN or BSN in progress and/or willingness to acquire within 3 years of hire, 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, including Microsoft Office and/or Google Suite platforms.
• Familiarity with hospital resources, community resources, and utilization management.

• Master’s degree.

• Required:
  
  NJ Licensed Registered Nurse, NJ Licensed Social Worker, or NJ Licensed Clinical Social Worker.
• Preferred:
  Care Management (CCMA or ACMA) certification.

• Regular contact with medical personnel and visitors.

If you feel the above description speaks directly to your strengths and capabilities, please apply today!

HMH is committed to pay equity and transparency for our team members. The posted rate of pay is a reasonable good‑faith estimate of the minimum base pay for this…