Care Transitions Discharge Planner (LPN)

Millennium Physician Group; Florida; On-site; USD 56,000 - 83,000; Full time

Benefits offered by this job

3 weeks PTO

8 paid holidays

Medical coverage

Dental coverage

Vision coverage

Basic Life Insurance

Short Term Disability

401(k) with match

Employee Wellness

Tickets at Work

Cell phone discounts

Dependent Care FSA

Voluntary Life

Long Term Disability

Critical Illness

Pet Insurance

Job summary

Millennium Physician Group in Florida is seeking a Discharge Planner to coordinate hospital discharge planning and care transitions within our Hospitalist program. You will assess patients' needs, develop individualized discharge plans, and collaborate with physicians, nurses, case managers, and community resources to ensure safe, timely post-acute care.

Responsibilities include educating patients, addressing barriers to discharge, documenting in the EHR, and coordinating post-acute services

Qualifications

• Registered Nurse, LPN, Social Worker preferred

Responsibilities

• Assess patients' discharge planning needs through review of medical records, interdisciplinary collaboration, patient interviews, and evaluation of clinical, functional, psychosocial, and environmental factors affecting post-discharge care.
• Develop and coordinate individualized discharge plans that align with physician orders, patient goals, payer requirements, and available community resources.
• Collaborate with hospitalists, nursing staff, case managers, therapists, pharmacists, social workers, and ancillary departments to coordinate timely, safe, and effective patient discharges.
• Arrange post-acute services including home health, skilled nursing facilities, rehabilitation services, durable medical equipment, hospice, outpatient therapies, transportation, and community-based resources as appropriate.
• Educate patients and caregivers regarding discharge instructions, medications, follow-up appointments, disease management, warning signs requiring medical attention, and available community resources.
• Identify barriers to discharge including insurance authorization delays, transportation needs, caregiver limitations, equipment availability, housing concerns, or social determinants of health, and coordinate appropriate interventions.
• Communicate with primary care providers, specialists, post-acute providers, payers, and external agencies to facilitate continuity of care and reduce avoidable readmissions.
• Document discharge planning assessments, care coordination activities, referrals, patient education, and transition plans accurately within the electronic health record in accordance with organizational standards and regulatory requirements.
• Monitor discharge timelines, transition metrics, and assigned patient caseloads while supporting organizational goals related to length of stay, readmission reduction, patient satisfaction, and quality outcomes.
• Participate in interdisciplinary rounds, quality improvement initiatives, patient safety activities, and care transition programs that improve discharge processes and patient outcomes.

Skills

Discharge planning

Care coordination

Team collaboration

Patient education

Education

RN license

LPN license

Social Worker license

Job description

Millennium Physician Group in Florida is seeking a Discharge Planner to coordinate hospital discharge planning and care transitions within our Hospitalist program. You will assess patients' needs, develop individualized discharge plans, and collaborate with physicians, nurses, case managers, and community resources to ensure safe, timely post-acute care.

Responsibilities include educating patients, addressing barriers to discharge, documenting in the EHR, and coordinating post-acute services