Care Coordination Navigator – Discharge & Transitions

Hackensack Meridian Health; Hackensack (NJ); On-site; USD 55,000 - 75,000; Full time

Job summary

Hackensack Meridian Health is seeking a Care Coordinator in Care Management to coordinate and facilitate the clinical progression of patient treatment and discharge plans. You will work with patients, families, physicians, and the care team to meet goals and arrange appropriate next-level care.

The role requires effective communication, collaboration across multidisciplinary teams, and strong documentation to support timely transitions and quality outcomes within this hospital system.

Responsibilities

• Assess patients by screening for discharge needs, meeting with patient/family to develop an individualized plan with the physician and care team.
• Facilitate communication among health care team and involve patient and family to minimize fragmentation of services and barriers to care.
• Maintain knowledge of community resources and refer patients to appropriate services in the community.
• Collaborate with multidisciplinary teams to ensure timely transitions to the next level of care.
• Develop discharge plans with patient and support persons to meet ongoing care needs.
• Document and share information with the team; ensure medical records reflect education, referrals, and authorizations.
• Participate on committees and workgroups; identify quality issues for review.
• Lead or participate in rounds; address discharge and length-of-stay concerns promptly.
• Reassess progress, adjust plans as needed, and record weekly reassessments in the medical record.
• Provide patients with resources and educate on discharge options and benefits.
• Provide CMS documents per regulatory guidelines (eg, Important Message before discharge, notices).
• Use social determinants of health screening tools at intake and coordinate with the team on care needs.
• Refer to a wide range of post-acute and community services as required (facility and home-based options).
• Maintain annual competencies and participate in ongoing training on Epic, Xsolis Cortex, BI, and Google suites.

Job description

Hackensack Meridian Health is seeking a Care Coordinator in Care Management to coordinate and facilitate the clinical progression of patient treatment and discharge plans. You will work with patients, families, physicians, and the care team to meet goals and arrange appropriate next-level care.

The role requires effective communication, collaboration across multidisciplinary teams, and strong documentation to support timely transitions and quality outcomes within this hospital system.