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Social Worker Care Coordinator LSW/MSW (Full-Time Days)

Company: Hackensack University Medical Center
Location: Hackensack
Posted on: June 6, 2021

Job Description:


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 Work.


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 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.
  • 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.
  • 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 from providers.
  • 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 Program.
  • 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 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 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 psychosocial assessment.
  • 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 setting.

Licenses and Certifications Required:

  • NJ Licensed Social Worker or New Jersey State Licensure for MSW.

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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