Hackensack Meridian Health

Follows State of New Jersey regulation for Social Work. ResponsibilitiesA day in the life of a Social Worker, Care Coordinator, LSW/MSW at Hackensack Meridian Health includes:Assesses all patients who are admitted for medical care to the trauma service, screened for potential discharge needs regardless of race, age, sex, religion, diagnosis and ability to pay.. Confirms the patient has a primary care provider upon discharge or refers appropriately to an ACO or FQHC.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, and placement in an extended care facility, durable medical equipment, and referral to complex care management team, ACO navigators and authorizations from providers.. Is responsible for trauma DSC and ACS social services related metrics (i.e.: CAGE screening, smoking cessation, PTSD counseling, and referrals, etc. 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.

care coordinator

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 Trauma SW 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 coordinators assesses, plans, 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 hand-off between acute & post-acute services. Follows State of New Jersey regulation for Social Work. ResponsibilitiesA day in the life of a Social Worker, Care Coordinator, LSW/MSW at Hackensack Meridian Health includes:Assesses all patients who are admitted for medical care to the trauma service, 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.Facilitates communication and coordination between 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. Provides social work intervention to patients and families to assist their ability to cope with traumatic injury and stress.Maintains current and up to date information of community resources and refers patients to those 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.Works collaboratively with all team members of the multi-disciplinary health care team and external to effect timely and appropriate transitions to the next appropriate level of care. Involved in crisis intervention and support activities. Responds to trauma codes to assist in the patient and family¿s support. Assists in gathering and proper notifications of family and community resources.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 provisions of continued care at home or in an appropriate extended care facility based upon the patient needs. Confirms the patient has a primary care provider upon discharge or refers appropriately to an ACO or FQHC.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, and placement in an extended care facility, durable medical equipment, and referral to complex care management team, ACO navigators and authorizations from providers.Participates actively on appropriate committee (i.e. Trauma DSC committee), workgroup, and/or meetings. Is responsible for trauma DSC and ACS social services related metrics (i.e.: CAGE screening, smoking cessation, PTSD counseling, and referrals, etc.). Is a positive problem solver. Identifies and refers quality issues for review to the Quality Management Program.Participates in Multidisciplinary Team Rounds, specific to trauma. 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 re-assessed no less than weekly in response to change in medical situation.Provides patients and families with resources and discharge options. Educations about risks and benefits of discharge options. Educates patients on how to obtain services and available heath care benefits. Patients are educated regarding their health status. Second Important message is provided to Medicare patients 24 to 48 hours prior to discharge.Participates in research as it relates to trauma and utilizes pertinent research for managing patient care issues. Provides in-services to the trauma service and other departments as requested. Demonstrates current knowledge of trauma care through the life span via literature, trauma rounds and conferences. Regularly attends and participates in Trauma Conferences, team rounds, multidisciplinary rounds, Trauma Committee, and other conferences/meetings as appropriate.Responsible for facilitating weekly inpatient family support sessions and responsible for referring patients for outpatient trauma support groups for post-discharge needs.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 FacilitiesSub-Acute FacilitiesLong-term Care FacilitiesAssisted Living FacilitiesAdult Day ProgramLevel 1 / Level 2 PAS/PASSAREARC PASHome CareHospice at Home/FacilityDME EquipmentAmbulance TransportationRenal Dialysis SlotsFinancial AssessmentNorth Hudson ClinicsMedication Indigent ProgramsCommunity LinkageEnd of Life IssuesBoarding Home PlacementMental Health ServicesHomeless PlacementMedicaidDivision of Child Protection and Permanency (DCP&P)Collaborate with Utilization Review NursesCompletes all other necessary duties as assigned by the trauma service with attention to detail and inca timely manner.Other duties as assigned. QualificationsEducation, Knowledge, Skills and Abilities Required:Master's of Social WorkTwo years of experience as a social worker in a health care setting.Trauma Certification in Social Work required within 1 year from date of hire.Licenses and Certifications Required:NJ Licensed Social Worker.Licenses and Certifications Preferred:NJ Licensed Clinical Social Worker.Certified Case Manager or Accredited Case Manager Certification.Trauma Certification in Social Work.Contacts:Regular contact with Medical Center personnel, patients and visitors.If you feel the above description speaks directly to your strengths and capabilities, then please apply today!

START NEW SEARCH