1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. Participates actively on appropriate committees, workgroups, and or meetings.
8. Identifies and refers quality issues for review to the Quality Management Program.
9. 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.
10. 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.
11. Provides patients and families with resources and discharge options. Educates regarding the risks and benefits of discharge options and any available health care benefits.
12. 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)
13. Utilizes social determinants of health screening tools and resources during each intake assessment.
14. 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.
15. 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
16. Maintains annual competencies and ensures training and continuing education of the team in applicable platforms. (Epic, Xsolis Cortex, BI, Google Suites)
17. Other duties and/or projects as assigned.
18. Adheres to HMH Organizational competencies and standards of behavior.

1. Bachelor's Degree in Nursing or related field, or Master's Degree in Social Work.
2. Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills.
3. Excellent verbal, written and presentation skills.
4. Moderate to expert computer skills.
5. Familiar with hospital resources, community resources, and utilization management.
6. Excellent written and verbal communication skills.
7. Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.

1. Master's degree.

1. NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker.
2. Care Management certification by a nationally recognized organization within 1 year.