discharge planner

Southeast Health

<div><h1 class="jobSectionHeader"><b>Southeast. Always the right career direction.</b></h1><p></p><h2 class="jobSectionHeader"><b>
Job Description Summary</b></h2>
The Clinical Transition Coach (CTC) assists in the safe and timely transition of patients from acute inpatient care to alternative levels of care, including but not limited to a home care program, palliative/hospice program, skilled nursing facility, or home setting appropriate to the patient&rsquo;s needs. The CTC performs activities essential to the discharge of the patient, and may also assist with the admissions process and/or other processes to facilitate patient throughput.<h2 class="jobSectionHeader"><br>
<b>
Job Description</b></h2><h3 class="jobSectionHeader"><b>
QUALIFICATIONS:</b></h3><ul><li>
Current (unencumbered) LPN license in the state of Alabama;</li><li>
Minimum of 3 years nursing experience in a medical surgical setting</li></ul><p></p><h3 class="jobSectionHeader"><b>
LANGUAGE/ COMMUNICATION SKILLS:</b></h3><ul><li>
Ability to read, write, and speak English;</li><li>
Ability to communicate effectively with individuals of various educational levels and cultural backgrounds via written and verbal formats;</li><li>
Excellent customer service skills and interpersonal skills</li></ul><p></p><p><b>
SKILLS:</b></p><ul><li>
Annual completion of competency requirements;</li><li>
Experience in operating personal computers, including operation of computer software in a Windows environment;</li><li>
Must be able to work in a self-directed environment, with ability to work as an integral member of the healthcare team;</li><li>
Position requires excellent conflict resolution, problem solving, leadership, and organizational skills, as well as written, and verbal communication skills.</li></ul><h2 class="jobSectionHeader"><br>
<b>
Shift</b></h2>
Day<h2 class="jobSectionHeader"><b>
Shift Details</b></h2>
8:00 am - 4:30 pm<h2 class="jobSectionHeader"><br>
<b>
FTE</b></h2>
1<h2 class="jobSectionHeader"><br>
<b>
Type</b></h2>
Regular<h2 class="jobSectionHeader"><br>
<b><i>
Join one of Forbes 500 best mid-sized employers in America.</i></b></h2><h2 class="jobSectionHeader"><b><i>
Equal Employment Employer</i></b></h2><h2 class="jobSectionHeader"><b><i>
Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.</i></b></h2></div>

CTC- Discharge Planning

Brown University Health

<div><ul><li>Job ID: JR-108277
</li><li>Entity: Rhode Island Hospital
</li><li>Location Name: Rhode Island Hospital
</li><li>City, State: Providence, RI
</li><li>Work Type: FULL TIME
</li><li>Hours Per Week: 36
</li><li>Shift: Day
</li><li>Posted Date: 4/11/2026
</li></ul><div><h2 class="jobSectionHeader"><b>SUMMARY</b></h2>
<p>
Reports to the Manager or Director of Case Management. Provides coordinated care support to facilitate and expedite patient care services. Participates in daily rounds and collaborates with the clinical healthcare team across the patient care continuum to include preadmission and post hospital discharge. As a member of that team, shares responsibility for the implementation of the discharge plan; ensures efficient and effective delivery of patient care services through the appropriate utilization of healthcare resources.</p>
<h2 class="jobSectionHeader"><b>
RESPONSIBILITIES</b></h2>
<ul>
<li><p>Partners with medical staff and other members of the healthcare team in collaboration with the patient/family to facilitate the plan of care for a defined patient population across the continuum of care. Identifies a high-risk patient population within the caseload for care management assessment screening and targets interventions in conjunction with the healthcare team within one business day of patient admission.</p>
</li>
<li><p>Participates in daily care rounds to collaborate with members of the patient's healthcare team as well as to evaluate and facilitate development and implementation of the discharge planning process. Develops the initial patient discharge plan and reviews with patient, family members and other members of the interdisciplinary team. Reassesses the discharge plan daily during collaborative care rounds.</p>
</li>
<li><p>Proactively builds post hospital referrals and sends to the Transition Care Coordinator when indicated to facilitate timely discharge.</p>
</li>
<li><p>Delivers Important Message follow-up notices to all Medicare patients according to CMS regulations. Follows CMS and DOH regulations in relationship to discharge guidelines and patient rights.</p>
</li>
<li><p>Coordinates the length of stay with the physician care team and patient. Ensures team is informed of insurance qualifiers that may affect the discharge plan. Discuss approaching discharge readiness of patients. Identify and assess readmitted patients and complex patients in collaboration with members of the healthcare team to coordinate discharge.</p>
</li>
<li><p>Advocates for the patient and advises the patient regarding financial implications of their discharge plan when coordinating care for the patient. Communicates the discharge plan, including post facility acceptance, to patients, families and all members of the care team.</p>
</li>
<li><p>Documents final discharge disposition in progress notes. Develops appropriate patient care reports to ensure safe patient handovers occur as a patient is transferred from one patient care area to the next. Provides care plan direction for the advancement of a patient care delivery system which supports managed care strategies and decreases readmission risk.</p>
</li>
<li><p>Acts as a change agent by identifying opportunities to improve patient flow and reduce service delays through problem resolution and follow-up.</p>
</li>
<li><p>Demonstrates a fundamental grounding in nursing theory and practice with a clinical background within a defined content area. Remains current on the latest concepts techniques and methods relative to his/her service.</p>
</li>
<li><p>Demonstrates knowledge of federal and state rules and regulations.</p>
</li>
<li><p>Reviews and acts as a change agent by identifying opportunities to improve patient flow and identifies and reduces service delays through problem resolution and follow-up. Identifies and tracks service and discharge patient delays.</p>
</li>
<li><p>Participates in departmental and/or interdepartmental quality improvement activities as requested: i.e. OpX teams weekly long LOS reviews interdisciplinary rounds readmission reviews. Participates in Orienting of New staff as requested.</p>
</li>
<li><p>Participates in ongoing education-related professional activities and affiliations to maintain an advanced level of knowledge of patient care services third party payer and managed care requirements and case management.</p>
</li>
</ul><h2 class="jobSectionHeader"><b>MINIMUM QUALIFICATIONS</b></h2>
<p>
Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.</p>
<h2 class="jobSectionHeader"><b>
BASIC KNOWLEDGE</b></h2>
<ul><li>Graduate of a School of Nursing with current license to practice as a Registered Nurse in the State of Rhode Island.</li>
<li>Bachelor's Degree Required.</li>
<li>Certification in Case Management by a nationally recognized organization preferred.</li>
<li>AHA BLS Provider Required.</li>
</ul><h2 class="jobSectionHeader"><b>EXPERIENCE</b></h2>
<p>
Three years of clinical experience with recent experience in case management, community case management, patient navigation, or discharge planning is strongly preferred. Strong analytical and interpersonal skills are required to provide guidance to and communicate daily with healthcare professionals, patients and families. Must exhibit a collaborative approach and method of communication to interact successfully on a daily basis with a wide and diverse population of both health care providers, insurers, patients and their families. Demonstrates knowledge and skills necessary to provide care to patients throughout the life span with consideration of aging processes, human development stages and cultural patterns in each step of the care process. Must be proficient in the use of Microsoft Office software including email and Outlook calendar and have basic keyboarding skills.</p>
<h2 class="jobSectionHeader"><b>
WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS</b></h2>
<p>
General hospital environment with occasional stressful conditions associated with patient care. Risk of exposure to blood borne pathogens and disease is minimized and controlled by adherence to Hospital Infection Control policy and procedures. Must be able to make hospital rounds through various patient care areas either by walking or through some other mobile means. Visual acuity and finger dexterity is needed to review and carry medical records, navigate through automated system screens and type on a typical computer terminal keyboard. Lifting of up to 10 lbs. may be necessary to transport items from one care unit to the next.</p>
<h2 class="jobSectionHeader"><b>
INDEPENDENT ACTION</b></h2>
<p>
Responds to individual patient-care situations demonstrating knowledge and skills acquired through education, certification and work experience.</p>
<h2 class="jobSectionHeader"><b>
SUPERVISORY RESPONSIBILITY</b></h2>
<p>
None.</p>
<h2 class="jobSectionHeader"><b>
Pay Range</b></h2>
<p>
$90,417.60 - $146,640.00</p>
<h2 class="jobSectionHeader"><b>
Location</b></h2>
<p>
Rhode Island Hospital - 593 Eddy Street Providence, Rhode Island 02903</p>
<h2 class="jobSectionHeader"><b>
Work Type</b></h2>
<p>
Monday - Friday 8-4:30; rotating weekends and holidays</p>
<h2 class="jobSectionHeader"><b>
Work Shift</b></h2>
<p>
Day</p>
<h2 class="jobSectionHeader"><b>
Driving Required</b></h2>
<p>
No</p>
<h2 class="jobSectionHeader"><b>
Union</b></h2>
<p>
United Nurses And Allied Professionals</p>
<p><i>
Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.</i></p></div></div>

Case Manager

Community Health Network

<div><div><div><div>Category</div>
<div>Nursing</div>
</div><div><div>Job Family</div>
<div>Case Manager</div>
</div><div><div>Department</div>
<div>Case Management</div>
</div><div><div>Schedule</div>
<div>Per Diem</div>
</div><div><div>Facility</div>
<div>Community Hospital South</div>
<div><div><div>1402 E County Line Rd</div><br>
<div>Indianapolis</div>, <div>IN</div> <div>46227</div><br>
<div>United States</div></div></div>
</div><div><div>Shift</div>
<div>PRN (as needed)</div>
</div><div><div>Hours</div>
<div>Variable</div><br>
</div></div><div><div><div><br>
<br>
<b>Join Community</b><br>
Community Health Network was created by our neighbors, for our neighbors. Over 60 years later, &ldquo;community&rdquo; is still the heart of our organization. It means providing our neighbors with the best care possible, backed by state-of-the-art technology. It means getting involved in the communities we serve through volunteer opportunities and benefits initiatives. It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients. And above all, it means exceptional care, simply delivered &mdash; and we couldn&rsquo;t do it without you.<br>
<br>
<b>Make a Difference</b><br>
The Case Manager is responsible for the assessment, planning, implementation, coordination, monitoring, and evaluation of services across the continuum of care to ensure quality patient outcomes and appropriate utilization of health care services. The Case Manager is responsible for supporting the healthcare team towards a smooth transition from one level of care to another in support of the patient/family.<br>
<br>
<b>Exceptional Skills and Qualifications</b><br>
Applicants for this position should be able to collaborate with others in a team setting, have excellent communication skills, and a positive attitude toward problem-solving.<br>
<br>
<ul><li>LCSW or LSW in the State of Indiana required.</li><li>Master&rsquo;s Degree in Social Work required.</li><li>2 + years of inpatient, outpatient, or home-base social work experience required.</li><li>Experience with quality improvement methodology preferred.</li><li>Demonstrates support of the hospital vision/mission statement.</li><li>Confers with nursing staff and other ancillary patient care departments regularly regarding ongoing discharge plans and barriers or delays.</li><li>Participates in developing and implementing the goal-directed plan of care, which is prioritized and based on intermediate goals and specific outcome criteria.</li><li>Coordinates and facilitates care in a knowledgeable, skillful, and consistent manner.</li><li>Performs documentation and patient records in a timely, accurate, clear, and concise manner in the transition to quality software.</li><li>Records pertinent date in required areas for other team members to provide care/services in an efficient, continuous manner.</li><li>Demonstrates awareness and sensitivity to the rights of patients/significant others, as identified within the institutional values.</li><li>Demonstrates sound knowledge base and actions in the care and decision making for designated patient populations and seeks guidance appropriately.</li><li>Demonstrates responsibility and accountability for own professional practice.</li><li>Participates actively in staff development activities for service line care management team, and nursing department personnel.</li><li>Collaborates with nurse case manager regarding discharge planning and use of the clinical pathways.</li><li>Demonstrates self-directed learning and participates in continuing education to meet own professional development.</li><li>Demonstrates awareness of legal issues in all aspects of patient care and unit function.</li><li>Participates in management of situations in a manner that reduces risk.</li><li>Participates in development and evaluation of the care management team functions.</li><li>Participates in meetings, reports, and other activities that support the care management team functions.</li><li>Demonstrates effective communication methods and skills, using lines of authority appropriately.</li><li>Conducts discharge planning assessments on identified patients that are consistent and provide for continuity of care for the patient.</li><li>Establishes the discharge plan with the patient, physician, and care management team for identified patients.</li><li>Implements the discharge plans for patients to include referrals to home health agencies return to ECF&rsquo;s transportation and any unmet needs to provide safe and appropriate transition to next level of care.</li><li>Demonstrates effective problem-solving techniques to communicate openly with members of the care management team and other staff.</li><li>Demonstrates skills as a resource and consultant to unit staff, care team members, and other staff.</li><li>Demonstrates skills as a resource and consultant to patients, families, and physicians.</li><li>Conducts effective problem-solving as a method of sound decision making.</li><li>Performs comprehensive assessment of patient/family goals as well as assessment of biophysical, psychosocial, environmental, financial, and discharge planning needs.</li><li>Procures services and serves as advocate on behalf of patients and families.</li><li>Acts as a liaison to post-hospital care providers and community health resources.</li><li>Demonstrates knowledge and understanding of Medicare, Medicaid, and third party payer guidelines.</li><li>Completes all necessary paperwork for final disposition.</li><li>Conducts personal interviews with patient, facilitates family conference and multidisciplinary conferences to formulate discharge plans.</li></ul></div></div>
<p><b>Why Community?
</b></p><p>At Community Health Network, we build teams that deliver exceptional care through empathy, communication and collaboration. We consider ALL an integral part of the exceptional patient experience. We PRIIDE ourselves on not having employees but Caregivers. Join our Community as we make a difference in your community.</p></div></div><p></p>

Case Manager- Licensed MSW- South- PRN

Humana

<div>
 <strong>
  Become a part of our caring community
  <br/>
  <br/>
 </strong>
 The Utilization Management Registered Nurse uses clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. You will report to the Manager of Utilization Management and serve as a member of the One Home/Home Solutions Utilization Management team. This team manages post-acute care services. These services include Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). The team's goal is to ensure members receive the appropriate level of care in the most appropriate setting.
 <br/>
 <br/>
 <strong>
  As a Utilization Management Registered Nurse
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
  </li>
  <li>
   Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers
  </li>
  <li>
   You will complete request determinations within established processing time frames. (i.e. 10 reviews per day?)
  </li>
  <li>
   You will communicate with providers, members, or other parties to facilitate care and treatment.
  </li>
  <li>
   You will help deliver coordinated care for our members
  </li>
  <li>
   You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Required Qualifications
  <br/>
  <br/>
 </strong>
 <strong>
  Use your skills to make an impact
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Must hold Compact Registered Nurse (RN) license in your state of residence
  </li>
  <li>
   Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting.
  </li>
  <li>
   Must be passionate about contributing to an organization focused on improving consumer experiences
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Previous experience in utilization management/utilization review for a health plan or acute care setting
  </li>
  <li>
   Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
  </li>
  <li>
   Experience working in a fully remote, metrics-focused role
  </li>
  <li>
   Experience as an MDS Coordinator or discharge planner in an acute care setting
  </li>
  <li>
   Experience as an RN for a Medicare Certified Home Health agency
  </li>
  <li>
   Health Plan or Medicare / Medicaid Experience
  </li>
  <li>
   Call center or triage experience
  </li>
  <li>
   BSN or bachelor's degree in a related field
   <br/>
   <br/>
  </li>
 </ul>
 Additional Information
 <br/>
 <br/>
 <strong>
  Work-at-Home Information
  <br/>
  <br/>
 </strong>
 To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
 <br/>
 <br/>
 <ul>
  <li>
   At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
  </li>
  <li>
   Satellite, cellular and microwave connection can be used only if approved by leadership.
  </li>
  <li>
   Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
  </li>
  <li>
   Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
  </li>
  <li>
   Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
   <br/>
   <br/>
  </li>
 </ul>
 Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
 <br/>
 <br/>
 <strong>
  Scheduled Weekly Hours
  <br/>
  <br/>
 </strong>
 40
 <br/>
 <br/>
 <strong>
  Pay Range
  <br/>
  <br/>
 </strong>
 The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
 <br/>
 <br/>
 $71,100 - $97,800 per year
 <br/>
 <br/>
 This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
 <br/>
 <br/>
 <strong>
  Description Of Benefits
  <br/>
  <br/>
 </strong>
 Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
 <br/>
 <br/>
 <strong>
  About Us
  <br/>
  <br/>
 </strong>
 About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health &ndash; delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
 <br/>
 <br/>
 <strong>
  Equal Opportunity Employer
  <br/>
  <br/>
 </strong>
 It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
</div>


Utilization Management Registered Nurse

HiredFirst

<div><p>Day Shift Sun - Thurs. 40hrs week, 8 hrs a day, can start between 8 and 9 am.. half hour lunch. Must have experience in social work, have an MSW standard for CA. Have acute care experience and active license. Must start ASAP. Need a true Experience in acute care/ED/homeless preferred.</p><h3 class="jobSectionHeader"><b>
Position Overview</b></h3><p>
The LCSW will assess patients&rsquo; psychosocial needs, coordinate discharge planning, and provide crisis intervention and counseling services.</p><h3 class="jobSectionHeader"><b>
Responsibilities</b></h3><ul><li><p>
Conduct psychosocial assessments</p></li><li><p>
Develop safe and effective discharge plans</p></li><li><p>
Coordinate with case management, nursing, and providers</p></li><li><p>
Provide counseling to patients and families</p></li><li><p>
Facilitate referrals to community resources</p></li><li><p>
Maintain accurate documentation</p></li></ul><h3 class="jobSectionHeader"><b>
Qualifications</b></h3><ul><li><p>
Active California LCSW license required</p></li><li><p>
Acute care hospital experience preferred</p></li><li><p>
Strong discharge planning experience</p></li><li><p>
Knowledge of insurance and community resources</p></li></ul>
#Workwolf</div>

Social Worker (LCSW)

Hackensack Meridian Health

<div>Overview:
<div>
Our team members are the heart of what makes us better.</div><div><br>
</div><div>At <b>Hackensack Meridian </b><b><i>Health</i></b> we help our patients live better, healthier lives &mdash; 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&rsquo;s also about how we support one another and how we show up for our community.</div><div><br>
</div><div>Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.</div><div></div><div><br>
The <b>Care Coordinator, Care Management</b> 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; 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</div>
Responsibilities:
<div>
A day in the life of a <b>Care Coordinator, Care Management</b> at <b>Hackensack Meridian Health</b> includes:</div><br>
<div></div><ul><li>
Assesses patients by screening 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 care plan in collaboration with the physician and other members of the health care team.
</li><li>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.
</li><li>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.</li><li>
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.</li><li>
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.</li><li>
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.
</li><li>Participates actively on appropriate committees, workgroups, and or meetings.</li><li>
Identifies and refers quality issues for review to the Quality Management Program.
</li><li>Participates in multidisciplinary rounds, specific to assigned units. Brings forth issues which impact on discharge as well as length of stay in a timely manner, for discussion and resolution.
</li><li>Performs appropriate reassessments and evaluates progress against care goals and the plan of care and revises plan, as needed. Ensures that the medical record reflects reassessment of the discharge plan at least weekly and upon any change in medical condition affecting the plan.
</li><li>Provides patients and families with resources and discharge options. Educates regarding the risks and benefits of discharge options and any available health care benefits.
</li><li>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, appeal and HINN notices)
</li><li>Utilizes social determinants of health screening tools and resources during each intake assessment.
</li><li>Collaborates with all members of the multidisciplinary team to support the following functions; crisis intervention, counseling support and referrals, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, hospital throughput.</li><li>
Referrals should be made to the following as required/needed: a. Acute rehabilitation facilities 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</li><li>
Maintains annual competencies and ensures training and continuing education of the team in applicable platforms. (Epic, Xsolis Cortex, BI, Google Suites)
</li><li>Other duties and/or projects as assigned.</li><li>
Adheres to HMH Organizational competencies and standards of behavior.</li></ul>
Qualifications:
<div><b>
Education, Knowledge, Skills and Abilities Required</b>:</div><ul><li>
BSN or BSN in progress and/or willing to acquire within 3 years of hire or transfer into the position; or Masters Degree in Social Work.</li><li>
Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills.</li><li>
Excellent verbal, written and presentation skills.</li><li>
Moderate to expert computer skills.
</li><li>Familiar with hospital resources, community resources, and utilization management.
</li><li>Excellent written and verbal communication skills.
</li><li>Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.</li></ul><div><b>
Education, Knowledge, Skills and Abilities Preferred</b>:
</div><ul><li>Master's degree.
</li></ul><div><b>Licenses and Certifications Required</b>:
</div><ul><li>NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker.</li></ul><div><b>
Licenses and Certifications Preferred</b>:
</div><ul><li>Care Management, CCMA or ACMA certification strongly preferred.</li></ul><div>
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!
</div>Starting Minimum Rate: Minimum rate of $90,750.40 Annually Job Posting Disclosure: HMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market-competitive total rewards package. The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non-discriminatory factors, including but not limited to: Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness. Experience: Years of relevant work experience. Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training. Skills: Demonstrated proficiency in relevant skills and competencies. Geographic Location: Cost of living and market rates for the specific location. Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization. Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered. Some jobs may also be eligible for performance-based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts. In addition to our compensation for full-time and part-time (20+ hours/week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.</div>

Care Coordinator, Care Management

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