Job Overview
Overview:
How have you impacted someone’s life today? At Hackensack Meridian Health our 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 Social Work Care Coordinator 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. The social work care coordinator assesses, plan and facilitates with patients/families and healthcare professionals involved in the patients care to meet treatment goals, expected length of stay and arrange for the appropriate next level of care. Oversees inter-facility transitions and handoff between acute & post-acute services. Follows State of New Jersey regulations for Social Work.
Responsibilities:
A day in the life of a Care Coordinator at Hackensack Meridian Health includes:
- Assesses all patients who are admitted for medical care, screened 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 plan in collaboration with the physician and other members of the health care team.
- Maintains communication and coordination between the members of the health care team and involves the patient/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 and up to date information of community resources and refers patients to the community resources which will enhance patient’s life. Consults with other community agencies and committees to identify potential resources to support patients and their families.
- Develops a discharge plan in collaboration with the patient/family patient caregiver, patient support persons and healthcare team that will provide maximum benefit for each patient. Ensures that the discharge plan will be the least restrictive environment that best meets the continuing care needs of the patient. Ensures provision of continued care at home or in an appropriate extended care facility based upon the patients needs.
- Documents and communicates information to the Multidisciplinary Team in order to coordinate and maximize care. The EMR reflects the education, coordination of home care services or in an appropriate extended care facility
- Participates in Multidisciplinary Team Rounds, specific to assigned units. Brings forth issues which impact on discharge as well as LOS to the team, in a timely manner for discussion and resolution.
- Reassesses periodically and evaluates against care goals and the plan of care and when indicated the plan or goals are revised. Medical records reflect that each patient’s discharge plan is reassessed no less than weekly in response to change in medical situation.
- Provides patients and families with resources and discharge options. Educates about risks and benefits of discharge options. Educates patients on how to obtain services and available health care benefits and corresponding financial obligations.
- Collaborates with all members of the multidisciplinary team to support the following functions: crisis intervention, counseling support and referrals, abuse/neglect, guardianship and psychosocial assessment.
- Referrals should be made to the following as required/needed.
- Acute Rehabilitation Facilities
- Sub-Acute Facilities
- Long-term Care Facilities
- Assisted Living Facilities
- Adult Day Program
- Level 1/Level 2 PAS/PASSAR
- EARC PAS
- Home Care
- DME Equipment
- Ambulance Transportation
- Renal Dialysis Slots
- Hospice at Home/Facility
- Financial Assessment
- Medication Indigent Programs
- Community Linkage
- End of Life Issues
- Boarding Home Placement
- Mental Health Services
- Homeless Placement
- Medicaid
- Abuse/neglect- Division of Child Protection and Permanancy (DCP&P), Adult Protective Services (APS), Ombudsman
- Other duties and/or projects as assigned.
- Adheres to HMH Organizational competencies and standards of behavior.
- Lifts a minimum of 2 lbs, pushes and pulls a minimum of 2 lbs, and stands a minimum of 4 hours a day.
Qualifications:
Education, Knowledge, Skills and Abilities Required:
- Masters of Social Work (MSW)
Education, Knowledge, Skills and Abilities Preferred:
- NJ Licensed Clinical Social Worker (LCSW)
- Two years experience as a social worker in an acute medical care setting
- Knowledge of community resources, disability, Medicare and Medicaid
- Ability to prioritize and multi- task in a fast past environment
Licenses and Certifications Required:
- NJ Licensed Social Worker (LSW)
If you feel the above description speaks directly to your strengths and capabilities, then please apply today!
