Care Management Navigator

Hackensack Meridian Health; Old Bridge (NJ); On-site; USD 83,000 - 101,000; Full time

Job summary

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

You will oversee interfacility transitions, document care, support committees, and ensure timely discharges while maintaining adherence to CMS guidelines.

Qualifications

• BSN or BSN in progress and/or willing to acquire within 3 years of hire; or Masters Degree in Social Work.
• Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills.
• Excellent verbal, written and presentation skills.
• Moderate to expert computer skills.
• Familiar with hospital resources, community resources, and utilization management.
• Excellent written and verbal communication skills.
• Proficient computer skills that may include Microsoft Office and/or Google Suite platforms.

Responsibilities

• Assess patients by screening for potential discharge needs and develop an individualized care plan with the physician and health care team.
• Facilitate communication and coordination among health care team members and involve patient/family in decisions to minimize fragmentation.
• Maintain information on community resources and refer patients to appropriate programs.
• Collaborate with multidisciplinary teams to secure timely transitions to the next level of care.
• Develop discharge plans with patient and support persons to meet ongoing care needs.
• Document and communicate information to coordinate care and obtain authorizations.
• Participate in committees, workgroups, and meetings.
• Identify and refer quality issues to the Quality Management Program.
• Participate in rounds focusing on discharge decisions and length of stay.
• Reassess progress and revise plans as needed; reflect changes in medical condition.
• Provide CMS documents to patients and families as required by guidelines (IM4, notices).
• Utilize social determinants of health screening tools during intake assessments.
• Coordinate with teams to support crisis intervention, counseling, referrals, and safeguarding tasks.
• Refer to facilities and services such as rehab, long-term care, home care, hospice, and others as needed.

Skills

Decision making

Communication skills

Leadership

Computer skills

Education

BSN or BSN in progress / MSW

RN license or Social Work license (NJ)

Care Management certification (CCMA/ACMA) preferred

Tools

MS Office / Google Suite

Job description

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

You will oversee interfacility transitions, document care, support committees, and ensure timely discharges while maintaining adherence to CMS guidelines.