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Description
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 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 Rehab Care Coordinator is a member of the healthcare team and is responsible for coordinating, communicating, and facilitating the clinical and fiscal progression of the patient's treatment and discharge plan. 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. Oversees interfacility transitions and handoff between acute and post-acute services as well as follows the state of New Jersey regulations for Social Work.
Responsibilities
A day in the life of a Rehab Care Coordinator at Hackensack Meridian Health includes:
1. Assesses patients by completing psychosocial assessment upon admission. 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. Responsible for functioning as the liaison among all parties involved with the patient both within the hospital and in the community as it relates to the development and implementation of a safe and appropriate discharge plan, as well as the supervision of clinical interventions that may become critical to the development and implementation of the discharge plan.
2. Facilitates communication and coordination between members of the health care team and involves the patient and family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the plan of care.
3. Assures responsiveness to payer systems by maintaining ongoing communication and serving as the primary contact for all external payer sources, in turn generating revenue, enhancing reimbursement, minimizing financial risk and assuring payment for the hospital. Maintains a thorough understanding of insurance coverage and benefits, providing interpretation to patients/families of their insurance and providing patient advocacy as needed.
4. Identifies and fulfills the requirements and needs of payer and referral sources, overseeing negotiations of continued stay rationale, length of stays, and appeals process. Initiates activities to develop positive business relationships with payers and referral sources in order to promote repeat business and represent the hospital as a quality institution.
5. Maintains current information of community resources and refers patients to those community resources appropriate for the patient's care. Consults with other community agencies and committees to identify potential resources to support patients and their families.
6. 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.
7. 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 discharge plan meets the continuing care needs of the patient.
8. Documents and communicates information to the multidisciplinary team in order to coordinate and maximize care. Ensures that the medical record reflects the education provided, coordination of services, referrals made and authorizations obtained.
9. Participates actively on appropriate committees, workgroups, and or meetings.
10. Identifies and refers quality issues for review to the Administrative Directors as needed.
11. Participates in multidisciplinary rounds weekly. Brings forth issues which impact on discharge as well as length of stay in a timely manner, for discussion and resolution.
12. Performs appropriate reassessments and evaluates progress against care goals and the plan of care and revises plan, as needed.
13. Provides patients and families with resources and discharge options. Educates regarding the risks and benefits of discharge options and any available health care benefits.
14. Provides appropriate CMS documents to the patient and family/support person as per regulatory guidelines (ie., Important Message 4 to 48 hours prior to discharge).
15. Utilizes social determinants of health screening tools and resources as appropriate.
16. Collaborates with all members of the multidisciplinary team to support the following functions; crisis intervention, counseling support and referrals, abuse and neglect Reporting guardianship.
17. Referrals should be made to the following as required/needed:
a. Residential diagnosis specific programs
b. Sub- Acute rehabilitation facilities
c. Long Term Care facilities
d. Assisted Living facilities
e. Adult day program
f. Level 1/Level 2 PASRR screening
g. EARC screening
h. Home Care
i. Hospice
j. Durable medical equipment
k. Transport
l. Dialysis
m. Financial assistance
n. Medication assistance
o. Palliative Care
p. Boarding home placement
q. Mental health services
r. Homelessness placement
s. Substance abuse placement
t. Division of Child Protection and Permanency
u. Adult Protective Services
18. Supports and participates in department/organization decisions, projects, and initiatives. Works cooperatively with staff, other departments in performance of job responsibilities. Attends in-services and meetings as scheduled to remain knowledgeable and informed regarding organizational goals and activities. Enhances professional growth and development through participation in educational programs, professional meetings, in-services and review of literature.
19. Maintains annual competencies and ensures training and continuing education of the team in applicable platforms.
20. Other duties and/or projects as assigned.
21. Adheres to HMH Organizational competencies and standards of behavior.
Qualifications
Education, Knowledge, Skills and Abilities Required:
1. Master's Degree in Social Work.
2. Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills.
3. Excellent verbal, written and presentation skills.
4. Moderate to expert computer skills.
5. Familiar with hospital resources, community resources, and utilization management.
Licenses and Certifications Required:
1. NJ Licensed Social Worker or NJ Licensed Clinical Social Worker.
If you feel the above description speaks directly to your strengths and capabilities, then please apply today!
Our Network
Hackensack Meridian Health (HMH) is a Mandatory Influenza Vaccination Facility
As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.
