Discharge Planner

Reid Health; United States; On-site; USD 55,000 - 75,000; Full time

Job summary

Reid Health is seeking a Discharge Planner to coordinate patient transitions across the care continuum. You will perform assessments, arrange referrals, and work with an interdisciplinary team to plan safe discharges and timely transfers.

The role emphasizes psycho-social, financial, and transition needs to reduce readmissions, with responsibilities for documenting activities, engaging families, and ensuring payer authorizations are in place.

Qualifications

• Bachelor’s degree in Social Work or equivalent field is required.
• Master’s degree in Social Work or equivalent field is preferred.
• 1 year of experience in a healthcare setting as a social worker or equivalent field is required.
• 3-5 years experience in healthcare setting as a social worker or equivalent field is preferred.

Responsibilities

• Works collaboratively with the Case Manager and interdisciplinary team to identify and establish patient transition plans and coordinates a timely, safe patient discharge/transfer.
• Coordinates post-hospitalization services for patients as identified by the interdisciplinary team.
• Understands the patient’s planned course of treatment to anticipate “transition readiness” and coordinate a timely discharge/transfer.
• Starts referrals timely to ensure the payer authorization process can begin early and avoid delays, as applicable.
• Collaborates with the patient/family in selecting and making post-hospitalization care arrangements; offers patients a choice of vendors and documents relationships and policies.
• Keeps the patient/family, Case Manager, and healthcare team well informed.
• Documents all transition coordination activities and interventions in the medical record.

Education

Bachelor’s degree in Social Work or equivalent field

Master’s degree in Social Work or equivalent field

Job description

Discharge Planner

7460 Patient Resources Services

Schedule: Day Shift. 40 hours weekly. 8:00a-4:30p. Occasional weekend and holiday rotation.

Type additional details specific to position and/or department.

About the Position

The Discharge Planner coordinates patient transition along the healthcare continuum through assessments, referrals and interdisciplinary planning. Coordinates the posthospitalization services as outlined in the patient’s transition plan. The Discharge Planner provides the necessary focus on the patient’s psycho-social, financial, and transition needs in order to promote optimal outcomes including reducing related and unplanned re-hospitalization. Refers patients to appropriate community services and resources. Alerts members of the interdisciplinary team to psycho-social and financial issues risk factors. The Discharge Planner applies the use of data in his/her practice; identifying where to focus efforts, the measurement of progress towards identified outcomes, and as an educational tool.

Overview of Responsibilities

• Works collaboratively with the Case Manager and interdisciplinary team to identify and establish patient transition plans and coordinates a timely, safe patient discharge/transfer.
• Coordinates post-hospitalization services for patients as identified by the interdisciplinary team.
• Understands the patient’s planned course of treatment to the degree necessary in order to anticipate “transition readiness” and coordinate a timely discharge/transfer.
• Starts referrals timely to ensure the payer authorization process can begin early and avoid delays, as applicable.
• Collaborates with the patient/family in the selection and making of post-hospitalization care arrangements; offers patients a choice of vendors. Discloses which vendors have a financial relationship with the hospital and documents both; follows Transition Management Policy.
• Keeps the patient/family, Case Manager, and healthcare team well informed.
• Communicates the relevant information to the agency/facility that will assume responsibility for continuing care after the patient’s release and documents as such.
• Documents all transition coordination activities and interventions in the medical record.
• Makes referrals to other department services as applicable to the patient’s needs to expedite a safe and timely discharge.
• Trends, analyzes, and reports outcomes, clinical process, and variance data to appropriate audiences.
• Participates in process and outcome improvement activities and helps facilitate approved practice changes.
• For the assigned population, attends appropriate physician and Nurse Leader meetings to report on trends, outcomes, and statistics. Receives and acts on feedback from physicians and nursing management related to Discharge Planning.
• Participates in all appropriate and/or required hospital-wide progress activities and efforts.
• Performs other duties as assigned to accomplish the goals of the organization.

This list of duties and responsibilities is not intended to be all-inclusive and can be

expanded to include other duties or responsibilities that management deems necessary.

Education & Experience

• Minimum education required: Bachelor’s degree in Social Work or equivalent field.
• Minimum education preferred: Mater’s degree in Social Work or equivalent field.
• Minimum experience required: 1 year of experience in a healthcare setting as a social worker or equivalent field.
• Minimum experience preferred: 3-5 years experience in healthcare setting as a social worker or equivalent field.