Care Transitions Specialist

Apploi; Los Angeles (CA); On-site; USD 65,000 - 90,000; Full time

Job summary

Astoria Healthcare Center in Sylmar is seeking a compassionate Discharge Planner to coordinate safe transitions from our skilled nursing facility to the next level of care. This role involves collaboration with residents, families, nursing staff, physicians, and rehabilitation services to ensure smooth discharge planning.

The position requires experience in discharge planning or care coordination, strong communication, and the ability to manage multiple priorities in a fast-paced healthcare

Qualifications

• Previous experience working in a skilled nursing facility (SNF) is required.
• Experience in discharge planning, social services, case management, or care coordination is strongly preferred.
• Knowledge of discharge planning procedures, community resources, and post-acute care services.
• Strong communication, organizational, and problem-solving skills.
• Ability to work collaboratively with an interdisciplinary team.
• Ability to manage multiple responsibilities and meet deadlines.
• Proficiency in computer systems and clinical documentation.
• Compassionate, resident-centered approach to care and communication.

Responsibilities

• Coordinate and facilitate discharge planning for residents transitioning from the facility to home or another care setting.
• Assess residents' discharge needs and identify appropriate resources and services to support a safe transition.
• Collaborate with the interdisciplinary team, including nursing, physicians, rehabilitation, and social services, to develop and implement discharge plans.
• Communicate with residents and families regarding discharge arrangements, recommendations, and available resources.
• Coordinate referrals to home health agencies, community resources, durable medical equipment providers, and other post-discharge services as needed.
• Assist residents and families with understanding follow-up care instructions and discharge recommendations.
• Maintain accurate, timely documentation related to discharge planning and coordination.
• Participate in care plan meetings and interdisciplinary team discussions as appropriate.
• Identify potential barriers to discharge and work with the care team to develop solutions.
• Ensure discharge planning activities follow facility policies and applicable regulations.
• Maintain confidentiality and demonstrate professionalism when working with residents, families, and healthcare professionals.

Skills

Communication

Organization

Problem-solving

Team collaboration

Time management

Clinical documentation

Job description

Astoria Healthcare Center in Sylmar is seeking a compassionate Discharge Planner to coordinate safe transitions from our skilled nursing facility to the next level of care. This role involves collaboration with residents, families, nursing staff, physicians, and rehabilitation services to ensure smooth discharge planning.

The position requires experience in discharge planning or care coordination, strong communication, and the ability to manage multiple priorities in a fast-paced healthcare