Discharge & Care Coordination Nurse

Penn Medicine, University of Pennsylvania Health System; Philadelphia (Philadelphia County); On-site; USD 70,000 - 95,000; Full time

Job summary

Penn Medicine seeks a Registered Nurse with discharge planning responsibilities to coordinate home care, DME, and post-hospital placements while partnering with families to ensure choices in care settings. The role emphasizes education on benefits and timelines, privacy, and timely communication of discharge plans.

Advanced EMR fluency (EPIC/Penn Chart) and use of Outlook/Teams are expected to support coordinated care, aging considerations, and seamless transitions to community resources.

Qualifications

• Registered Nurse - PA (Required)
• Bachelor of Arts or Science (Required)
• 2+ years Clinical Experience

Responsibilities

• Discharge planning activities: timely coordination of home care, DME, placements, hospice, community resources, transportation, and other discharge planning needs as they arise.
• Works with patient and family to assure provision of choice in post hospital setting.
• Educates patient / customers regarding scope and limitations of health care / insurance benefits.
• Respects each patient’s / customer’s personal dignity, right to privacy and confidentiality.
• Communicates expected discharge time frame.
• Keeps current with new providers, new technologies and treatment modalities, and new resources using internet and other sources.
• Recognizes and provides care based on the unique chronological issues and needs of the older adult.
• Interacts with the patient and family in a developmentally appropriate manner.
• Discharge Planning: Completes timely and detailed assessment of patient and family social, emotional and/or discharge needs and health care benefits.
• Develops and facilitates specific plan to address problems and/or concerns identified by patients, families and health care team.
• Identifies and consistently documents delays
• elevates issues appropriately.
• Effectively communicates discharge plan with patients, families and health care team.
• Documents ongoing assessments and plan of care in patient record (EPIC).
• Successfully assists patient in moving to the next level of care with transfers to home, agencies, and facilities and with referral to appropriate community resources.
• Participates and drives accountability in daily interdisciplinary meetings.
• New Technology / Computer Systems: Keeps current with new systems (SafetyNet, Penn Chart, Haiku, etc.).
• Incorporates technology into daily assignment (Outlook, Microsoft Teams, shared drive, Internet).

Skills

Discharge planning

Patient education

Interdisciplinary collaboration

Communication

Education

Bachelor of Arts or Science (Required)

Tools

EPIC

Penn Chart

Haiku

Outlook

Microsoft Teams

Job description

Penn Medicine seeks a Registered Nurse with discharge planning responsibilities to coordinate home care, DME, and post-hospital placements while partnering with families to ensure choices in care settings. The role emphasizes education on benefits and timelines, privacy, and timely communication of discharge plans.

Advanced EMR fluency (EPIC/Penn Chart) and use of Outlook/Teams are expected to support coordinated care, aging considerations, and seamless transitions to community resources.