Discharge Planner, Social Services

Jobtailor; Winchester (VA); On-site; USD 60,000 - 78,000; Full time

Job summary

Jobtailor seeks a skilled Social Worker to lead holistic patient assessments and discharge planning for medically and socially complex cases. You will coordinate with clinical partners, provide crisis support, and ensure smooth transitions across care settings.

Requirements include a Bachelor's in Social Work and BLS certification, with medical setting experience preferred. Strong communication and documentation skills are essential.

Qualifications

• Bachelor’s degree from an accredited social work program is required.
• Master’s degree is preferred.
• BLS Certification (American Heart Association) required prior to orientation.
• Experience in a medical setting is preferred.
• Ability to recognize, identify, and report abuse/neglect.

Responsibilities

• Provide holistic patient assessments and develop individualized discharge plans.
• Coordinate care with clinical partners to achieve realistic outcomes.
• Ensure timely discharges for medically and socially complex patients.
• Offer crisis intervention and emotional support to patients and families.
• Educate on community resources and assist referrals for continuity of care.
• Maintain documentation in the medical record and communicate across teams.

Skills

Holistic Patient Assessment

Individualized Care Planning

Crisis Intervention

Psychosocial Assessment

Discharge Planning

Knowledge Of Abuse Indicators

Documentation In Medical Record

Resource Navigation

Interdisciplinary Care Coordination

Knowledge Of Clinical Standards

Education

Bachelor's Degree In Social Work

Tools

Windows-Based Programs

Microsoft Word

Email

Job description

• Provides holistic patient assessments and develops individualized care plans addressing social, emotional, medical, spiritual, and physical needs.


• Ensures safe, timely discharges for medically and socially complex patients.


• Offers psychosocial support and resource navigation.


• Coordinates patient care with clinical partners to achieve realistic and desirable outcomes.


• Develops, implements, and communicates discharge plans for medically complex cases, ensuring documentation in the medical record.


• Facilitates interdisciplinary care planning meetings and delegates tasks to support team members.


• Utilizes post‑acute care facilities and collaborates with financial partners for safe and effective discharge planning.


• Conducts psychosocial assessments to identify long‑term care needs and barriers to discharge.


• Provides crisis intervention and emotional support for patients and families with complex psychosocial needs.


• Supports patients and families with emotional needs related to chronic, acute, or terminal illness.


• Assesses substance abuse, advanced directives, and medical decision‑making needs; assists with completion of related forms.


• Educates patients and families on community resources and assists with referrals for continuity of care.


• Maintains contact with referral sources until resources are confirmed, ensuring seamless transitions across the continuum of care.


• Coordinates legal processes for guardianships, adoptions, advance directives, and protective services.


• Makes timely referrals to CPS/APS as required by state law and testifies in court when necessary.


• Ensures compliance with Medicare, Medicaid, and commercial insurance requirements for post‑acute care.


• Completes Medicaid screening paperwork and maintains accurate, timely documentation of plans and status updates.


• Communicates effectively with patients, families, physicians, and care teams to support transitions of care.


• Partners with leadership to address discharge delays, barriers, and emerging trends.


• Performs other duties as assigned.

Requirements

• Bachelor’s degree from an accredited social work program or equivalent is required.


• Master’s degree from an accredited social work program or equivalent is preferred.


• Previous social work experience in a medical setting is preferred.


• BLS Certification (Basic Life Support) - American Heart ‘Healthcare Provider’ (HCP) - AHA approved required.


• New hires must have American Heart Association (AHA) appropriate certification prior to completion of orientation.


• Ability to recognize, identify, and report signs and symptoms of suspected abuse and/or neglect.


• Knowledge of abuse/neglect indicators and reporting requirements.


• Knowledgeable in stages of human growth and development across neonate, pediatric, adult, and geriatric populations.


• Familiarity with third-party reimbursement, Medicaid processes/plans for Virginia and West Virginia, and discharge planning processes.


• Knowledge of funding, resources, services, clinical standards, and outcomes.


• Strong verbal and written communication skills.


• Ability to interact and collaborate effectively within a multidisciplinary team.


• Excellent interpersonal skills with all levels of internal and external customers.


• Demonstrated critical thinking and creative problem-solving abilities.


• Ability to be innovative and flexible in responding to rapidly changing needs and priorities.


• Proficient organizational and planning skills.


• Ability to work independently, manage multiple priorities, and tolerate frequent interruptions and a demanding workload.


• Self-directed with strong time management capabilities.


• Experience with computer technology, including Windows‑based programs, email, and Microsoft Word.

Core Competencies

Demonstrates expertise in holistic patient assessments and individualized care planning, ensuring compliance with Medicare and Medicaid requirements. Proficient in crisis intervention, resource navigation, and interdisciplinary collaboration to support complex patient needs.

Highest-signal resume keywords

• Bachelor's Degree In Social Work


• BLS Certification


• Social Work Experience In Medical Setting


• Knowledge Of Medicaid Processes


• Strong Verbal And Written Communication Skills

ATS Optimization Keywords

Hard Skills

• Holistic Patient Assessment


• Individualized Care Planning


• Crisis Intervention


• Psychosocial Assessment


• Discharge Planning


• Knowledge Of Abuse Indicators


• Documentation In Medical Record


• Resource Navigation


• Interdisciplinary Care Coordination


• Knowledge Of Clinical Standards

Soft Skills

• Excellent Interpersonal Skills


• Critical Thinking


• Creative Problem‑Solving


• Ability To Collaborate Effectively


• Strong Time Management

Certifications & Qualifications

• BLS Certification


• American Heart Association Certification

Industry Keywords

• Medicare Compliance


• Medicaid Screening


• Post-Acute Care


• Third-Party Reimbursement


• Guardianship Processes


• CPS/APS Reporting


• Continuity Of Care


• Patient Discharge Planning


• Multidisciplinary Team Collaboration


• Emotional Support

Tools & Technologies

• Windows-Based Programs


• Microsoft Word


• Email