Senior Care Coordination Specialist

About the role

Rutgers Biomedical and Health Sciences (RBHS) takes an integrated approach to educating students, providing clinical care, and conducting research to improve human health. Aligned with Rutgers University–New Brunswick, RBHS includes eight schools, a behavioral health network, and five centers and institutes focusing on cancer treatment and research, neuroscience, advanced biotechnology and medicine, environmental and occupational health, and health care policy and aging research. The Senior Care Coordination Specialist will work as the Licensed Social Work/Licensed Associate Counselor Mental Health Clinician within the Department of Infectious Disease Practice at New Jersey Medical School (NJMS). The role manages daily workflow to achieve high‑quality care management delivery and positive clinical outcomes while meeting administrative and contractual performance targets, documentation standards, and billing requirements of grant programs.

Responsibilities

• Assess and work collaboratively with patients, medical providers, designated family/significant others, and community support service providers to address needs identified in the patient’s health and psychosocial risk assessment and implement a plan of care based on those needs.
• Interview clients, review records, and confer with other professionals to evaluate mental or physical condition of client or patient.
• Conduct and complete a biopsychosocial assessment including functional status, mental health status, acuity level, prognosis/diagnosis, and assess the need for treatment services and resources.
• Perform financial eligibility screening every six (6) months and assist patients to obtain health coverage if applicable.
• Facilitate the development and implementation of a comprehensive, multi‑disciplinary plan of care for patients with complex mental health and/or substance abuse and socio‑economic problems, in collaboration with physicians and other healthcare team members.
• LSW/L