Care Transitions Lead - Social Work & Discharge Planning

adventhealth; Orlando (FL); On-site; USD 70,000 - 95,000; Full time

Job summary

AdventHealth in Orlando, FL seeks a skilled Care Manager to coordinate discharge planning and post-acute care for patients across inpatient, observation, and emergency settings. You will assess psychosocial factors, collaborate with families, and develop comprehensive care plans to ensure timely transitions.

Requires a Master’s degree and 2+ years in care management. Strong communication and data analysis skills, with proficiency in Outlook and EMR systems, are essential.

Qualifications

• Master’s degree required in care management or related field.
• Minimum 2+ years of care management experience.
• Experience with discharge planning and collaboration with multidisciplinary teams.

Responsibilities

• Provides grief counseling, disease adjustment support, crisis intervention, goals of care planning support, and de-escalation services for patients as appropriate.
• Assesses patients' and families' wholistically for discharge planning needs in inpatient, observation and/or emergency departments.
• Reviews the medical record and incorporates clinical, social, and financial factors into the transition of care plan.
• Develops discharge plans with contingency plans throughout the hospital stay for timely care coordination and post-acute care arrangements.
• Communicates with post-acute care services to ensure continuity of care and complete medical records.
• Participates in multi-disciplinary rounds to review patient status, level of care, and discharge plans and escalates delays to leadership as needed.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, barriers to progression, and patient/family needs.
• Provides patient and family advocacy and supports patient rights during hospitalization.
• Communicates with payors for post-acute care authorization as needed.
• Assesses readmitted patients for reasons and coordinates appropriate follow-up actions.

Skills

Interpersonal communication

Critical thinking

Psychosocial assessment

Customer service

Cultural competency

Organization

Outlook & EMR

Adaptability

Care transitions

Community resources

Interview skills

Leadership

Data analysis

Discharge planning

Care regulations

Resource coordination

Education

Master's degree in Social Work, Nursing, or related field

Tools

Outlook

Electronic Medical Records (EMR)

Job description

AdventHealth in Orlando, FL seeks a skilled Care Manager to coordinate discharge planning and post-acute care for patients across inpatient, observation, and emergency settings. You will assess psychosocial factors, collaborate with families, and develop comprehensive care plans to ensure timely transitions.

Requires a Master’s degree and 2+ years in care management. Strong communication and data analysis skills, with proficiency in Outlook and EMR systems, are essential.