Discharge Planner

Cfg Health System Llc; Town of Goshen (NY); On-site; USD 65,000 - 90,000; Full time

Job summary

Cfg Health System Llc in Goshen, NY seeks a Discharge Planner to coordinate safe, timely discharge planning across medical, behavioral health, social services, and community partners.

You will develop individualized plans addressing housing, transportation, medications, and follow-up care, educate patients, and advocate to overcome barriers. Strong collaboration, confidentiality, and knowledge of community resources are essential in this role.

Qualifications

• Assess discharge planning needs and identify barriers to transition of care.
• Develop individualized discharge plans with patients, providers, and team members.
• Coordinate discharge planning activities from admission through discharge.
• Coordinate referrals to medical, behavioral health, substance use, housing, and community programs.
• Educate patients about discharge plans, follow-up care, medications, and resources.

Responsibilities

• Communicate with hospitals, facilities, and outside providers.
• Maintain patient confidentiality and obtain necessary releases.
• Document discharge planning activities in the EMR.
• Follow up on referrals and appointments prior to discharge.
• Advocate for patients to access community resources and services.

Skills

Interpersonal skills

Organizational skills

Communication

Collaboration with correctional staff

Problem-solving

Education

Bachelor's degree in criminal justice, social work, psychology, mental health, human services, or related field

Master's preferred

CASAC license

Tools

EMR system

Referral coordination software

Job description

FT Day: Monday-Friday 9 am-5 pmPosition SummaryThe Discharge Planner is responsible for coordinating and facilitating safe, timely, and effective discharge planning for patients. This position works collaboratively with medical, behavioral health, nursing, social services, community providers, patients, families, and other stakeholders to develop individualized discharge plans that address ongoing healthcare, behavioral health, housing, medication, and community support needs.The Discharge Planner ensures continuity of care by coordinating referrals, appointments, medications, transportation, community resources, and other services necessary to support successful transition from the facility to the next level of care.Position RequirementsA bachelor’s degree is required in criminal justice, Social Work, Psychology, mental health, human services, or a related field.Master's preferredCASAC licenseKnowledge of medication-assisted treatment practices is required.Experience working with individuals involved in the criminal justice system preferred.Strong interpersonal, organizational, and communication skills.Ability to work collaboratively with correctional staff, community partners, and treatment providers.Essential Duties and ResponsibilitiesAssess patients' discharge planning needs and identify potential barriers to successful transition of care.Develop individualized discharge plans in collaboration with patients, healthcare providers, and interdisciplinary team members.Coordinate discharge planning activities from admission through discharge to ensure continuity of care.Coordinate referrals to medical, behavioral health, substance use, social service, housing, and community-based programs as appropriate.Schedule follow-up medical, psychiatric, counseling, specialty, and primary care appointments.Coordinate medication needs and ensure appropriate prescriptions, medication information, and continuity of treatment are addressed prior to discharge.Communicate with hospitals, rehabilitation facilities, treatment programs, community providers, residential programs, and other outside agencies.Obtain and provide appropriate clinical and discharge-related information to receiving providers while maintaining patient confidentiality.Assist patients in identifying and accessing community resources, including healthcare, behavioral health, substance use treatment, housing, transportation, financial assistance, and social services.Identify patients requiring additional support or specialized services following discharge and make appropriate referrals.Coordinate transportation arrangements when necessary to facilitate safe discharge.Monitor pending referrals, appointments, medical records, and other discharge requirements to ensure completion prior to release.Participate in interdisciplinary treatment team meetings and communicate discharge planning updates and barriers.Maintain accurate and timely documentation of discharge planning activities in the electronic medical record.Follow applicable federal, state, and facility regulations regarding confidentiality, patient rights, and release of information.Obtain appropriate releases of information when required.Educate patients regarding their discharge plans, follow-up appointments, medications, treatment recommendations, and available community resources.Advocate for patients and assist in resolving barriers that may interfere with successful continuity of care.Collaborate with nursing, medical, behavioral health, case management, social work, and administrative staff to coordinate services.Follow up on patients' discharge arrangements as appropriate and communicate changes or concerns to the appropriate clinical team.Maintain current knowledge of available community resources and healthcare providers.Assist with identifying gaps in community services and developing alternative plans when preferred services are unavailable.Respond to urgent discharge planning needs and assist with developing safe alternatives when discharge plans change unexpectedly.Perform other duties and responsibilities as assigned.Organizational ExpectationsDemonstrates professionalism, integrity, accountability, and respect in all interactions.Maintains confidentiality of patient, employee, and organizational information.Communicates effectively with patients, families, coworkers, supervisors, and external providers.Works collaboratively as a member of the interdisciplinary healthcare team.Demonstrates sound judgment, critical thinking, and problem-solving skills.Maintains accurate, timely, and complete documentation.Follows all organizational policies, procedures, safety standards, and applicable laws and regulations.Demonstrates cultural sensitivity and respect for individuals from diverse backgrounds.Maintains professional boundaries and ethical standards.Promotes a safe, supportive, and respectful environment for patients and staff.Physical DemandsAbility to sit, stand, walk, and move throughout the facility as required.Ability to use a computer and other office equipment for extended periods.Ability to communicate effectively in person, by telephone, and electronically.May occasionally be required to move or carry light office materials.Ability to work in a healthcare or secure facility environment and comply with applicable safety and security procedures.