Care Coordinator, Care Management (Per Diem)
Location: RIVERVIEW MEDICAL CENTER, Borough of Red Bank, New Jersey
Requisition #: 2025-168291 | Shift: Day | Status: Per Diem
Overview
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 to succeed. Our culture is rooted in connection and collaboration, and we are committed to supporting each other and our community.
In this role, you will coordinate, communicate, and facilitate the clinical progression of the patient’s treatment and discharge plan, ensuring that care goals are met and transitions between acute, post‑acute, and community services are smooth.
Responsibilities
* Assess patients by screening for potential discharge needs regardless of race, age, sex, religion, diagnosis, and ability to pay.
* Meet directly with patients and families to assess needs and develop individualized care plans in collaboration with physicians and other healthcare team members.
* Facilitate communication and coordination among team members, involve patients and families in decision‑making, and minimize fragmentation of services.
* Maintain current information on community resources and refer patients to appropriate services.
* Collaborate with multidisciplinary and post‑acute care teams to secure timely and appropriate transitions to the next level of care.
* Develop and document discharge plans that meet patients’ continuing care needs.
* Communicate information to the multidisciplinary team and ensure the medical record reflects education, coordination, referrals, and authorizations.
* Participate actively in appropriate committees, workgroups, and meetings.
* Identify and refer quality issues for review by the Quality Management Program.
* Participate in multidisciplinary rounds and raise discharge‑related issues in a timely manner.
* Perform reassessments and evaluate progress against care goals; revise plans as needed.
* Educate patients and families on discharge options, risks, benefits, and available healthcare benefits.
* Provide CMS documents to patients and families per regulatory guidelines (e.g., Important Message 4, Appeal, and HINN notices).
* Utilize social determinants of health screening tools and resources during each intake assessment.
* Collaborate with the multidisciplinary team on crisis intervention, counseling support, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation and capacity management, and hospital throughput.
* Maintain annual competencies and ensure training and continuing education of the team in applicable platforms (Epic, Xsolis Cortex, BI, Google Suite).
* Other duties and projects as assigned.
* Adhere to HMH organizational competencies and standards of behavior.
Referrals
* Acute rehabilitation facilities
* Sub‑Acute rehabilitation facilities
* Long‑term care facilities
* Assisted living facilities
* Adult day program
* Level 1/Level 2 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
* Division of Child Protection and Permanency
* Adult Protective Services
Qualifications
Education, Knowledge, Skills, and Abilities Required
* BSN or BSN in progress and willing to obtain within 3 years of hire, or master’s degree in Social Work.
* Effective decision‑making, creative problem‑solving, and influential leadership skills.
* Excellent verbal, written, and presentation skills.
* Moderate to expert computer skills.
* Familiarity with hospital resources, community resources, and utilization management.
Education, Knowledge, Skills, and Abilities Preferred
* Master’s degree.
Licenses and Certifications Required
* NJ Licensed Registered Nurse OR NJ Licensed Social Worker OR NJ Licensed Clinical Social Worker.
Licenses and Certifications Preferred
* Care Management, CCMA or ACMA certification strongly preferred.
Compensation
Minimum rate of $43.63 hourly.
HMH is committed to pay equity and transparency. The posted rate is an estimate of the minimum base pay and may differ from the offer based on market data, experience, education, and other factors.
Benefits include health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.
Equal Opportunity Employer
Hackensack Meridian Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, breastfeeding, genetic information, disability, marital status, or veteran status.
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