Social Worker Care Coordinator LSW/MSW (Full-Time Days)
Company: Hackensack University Medical Center
Posted on: June 6, 2021
How have you impacted someone's life today? At Hackensack
Meridian Health our healthcare 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 Worker 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 handoff between acute & post-acute
services. Follows State of New Jersey regulation for Social
A day in the life of a Social Worker 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
- 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
- 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
- Develops a discharge plan, in collaborations 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
- Participates actively on appropriate committee, workgroup,
and/or meetings. Is a positive problem solver. Identifies and
refers quality issues for review to the Quality Management
- 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
- 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
- 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 4 to 48
hours prior to discharge.
- Collaborates with all members of the multidisciplinary team to
support the following functions; crisis intervention, counseling
support and referrals, abuse/neglect, adoption, guardianship, and
- Referrals should be made to the following as required/needed:
a. Acute Rehabilitation Facilities b. Sub-Acute Facilities c.
Long-term Care Facilities d. Assisted Living Facilities e. Adult
Day Program f. Level 1 / Level 2 PAS/PASSAR g. EARC PAS h. Home
Care I. Hospice at Home/Facility j. DME Equipment k. Ambulance
Transportation l. Renal Dialysis Slots m. Financial Assessment n.
North Hudson Clinics o. Medication Indigent Programs p. Community
Linkage q. End of Life Issues r. Boarding Home Placement s. Mental
Health Services t. Homeless Placement u. Medicaid v. Division of
Child Protection and Permanency (DCP&P) w. Collaborate with
Utilization Review Nurses
- Completes all other necessary duties with attention to detail
and in a timely manner.
- Other duties as assigned.
Education, Knowledge, Skills and Abilities Required:
- Masters of Social Work
- Two years experience as a social worker in a health care
Licenses and Certifications Required:
- NJ Licensed Social Worker or New Jersey State Licensure for
Licenses and Certifications Preferred:
- NJ Licensed Clinical Social Worker.
If you feel the above description speaks directly to your
strengths and capabilities, then please apply today!
Keywords: Hackensack University Medical Center, Hackensack , Social Worker Care Coordinator LSW/MSW (Full-Time Days), Other , Hackensack, New Jersey
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