Care Coordinator, Care Management - Per Diem
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About The Position
The Care Coordinator, Care Management Per Diem at Hackensack Meridian Health plays a crucial role in the healthcare team, focusing on the coordination, communication, and facilitation of the clinical progression of patients' treatment and discharge plans. This position is accountable for a designated patient caseload, where the Care Coordinator assesses, plans, and collaborates with patients, families, and the multidisciplinary team to meet treatment goals and expected lengths of stay. The role involves arranging for the appropriate next level of care and overseeing interfacility transitions and handoffs between acute and post-acute services. In this position, the Care Coordinator will assess patients by screening for potential discharge needs, regardless of race, age, sex, religion, diagnosis, or ability to pay. They will meet directly with patients and their families to assess needs and develop individualized care plans in collaboration with physicians and other healthcare team members. The Care Coordinator will facilitate communication and coordination among healthcare team members, ensuring that patients and families are involved in the decision-making process to minimize fragmentation of services and manage resources effectively. The role also requires maintaining current information on community resources and referring patients to appropriate services. The Care Coordinator will work collaboratively with multidisciplinary and post-acute care teams to secure timely transitions to the next level of care. They will develop discharge plans in collaboration with patients and support persons, ensuring that these plans meet the continuing care needs of the patients. Documentation and communication of information to the multidisciplinary team are essential to maximize care, and the Care Coordinator will participate actively in committees and meetings to address quality issues and improve patient outcomes. Additionally, the Care Coordinator will perform reassessments, evaluate progress against care goals, and revise plans as necessary. They will provide patients and families with resources and discharge options, educate them about the risks and benefits of these options, and ensure compliance with regulatory guidelines. The role also involves utilizing social determinants of health screening tools during assessments and collaborating with the multidisciplinary team to support various functions, including crisis intervention and psychosocial assessments. The Care Coordinator will maintain annual competencies and ensure ongoing training and education for the team.
