Discharge Planner , Social Services - Full Time First Shift

Valley Health System; Virginia; Presencial; USD 36.000 - 55.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Zero-Deductible Health Plan

Dental and vision insurance

Generous Paid Time Off

Tuition Assistance

Retirement Savings Match

Employee Assistance Program

Wellness program

Descripción de la vacante

Valley Health System is seeking a Discharge Planner to coordinate holistic discharge planning for medically and socially complex patients. You will lead assessments, develop personalized care plans, and connect patients with community resources while supporting guardianship and advance directive processes.

Requirements include a Bachelor’s degree in social work (Master’s preferred) and experience in healthcare settings.

Formación

• Bachelor’s degree in social work is required.
• Master’s degree in social work is preferred.
• Experience in a medical setting is advantageous.

Responsabilidades

• Perform holistic patient assessments and develop care plans.
• Coordinate discharge plans with interdisciplinary teams.
• Educate patients and families about community resources and follow-up.
• Assist with guardianships, advance directives, and protective services as needed.
• Maintain documentation and communicate transitions of care to relevant parties.

Conocimientos

Social work

Crisis intervention

Communication

Multidisciplinary teamwork

Documentation

Educación

Bachelor’s in social work

Master’s in social work preferred

Herramientas

Microsoft Word

Windows

Email

Descripción del empleo

As one of the nation's Top 15 Health Systems, recognized by Premier and Modern Healthcare, Valley Health is a place where excellence, compassion, and purpose come together. This distinction reflects our commitment to exceptional patient care, clinical quality, and the caregivers who make it all possible.

Department SOCIAL SERVICES - 207170 Worker Sub Type Regular Work Shift First Shift (United States of America) Pay Range $26.45 - $39.68

Job Description The Discharge Planner provides holistic patient assessments and develops individualized care plans addressing social, emotional, medical, spiritual, and physical needs. This role ensures safe, timely discharges for medically and socially complex patients while offering psychosocial support and resource navigation.

Responsibilities include coordinating care with interdisciplinary teams, organizing treatment plans, identifying discharge needs, educating on community resources, and intervening in cases of abuse, neglect, or guardianship.

The position also supports decision-making for end-of-life care and Medical Power of Attorney.

• Coordinate patient care with clinical partners to achieve realistic and desirable outcomes.
• Develop, implement, and communicate discharge plans for medically complex cases, ensuring documentation in the medical record.
• Facilitate interdisciplinary care planning meetings and delegate tasks to support team members.
• Utilize post-acute care facilities and collaborate with financial partners for safe and effective discharge planning.
• Conduct psychosocial assessments to identify long-term care needs and barriers to discharge.
• Provide 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.
• Assessment for substance abuse, advanced directives, and medical decision-making needs; assist with completion of related forms.
• Educate patients and families on community resources and assist with referrals for continuity of care.
• Maintain contact with referral sources until resources are confirmed, ensuring seamless transitions across the continuum of care.
• Coordinate legal processes for guardianships, adoptions, advance directives, and protective services.
• Make timely referrals to CPS/APS as required by state law and testify in court when necessary.
• Ensure compliance with Medicare, Medicaid, and commercial insurance requirements for post-acute care.
• Complete Medicaid screening paperwork and maintain accurate, timely documentation of plans and status updates.
• Communicate effectively with patients, families, physicians, and care teams to support transitions of care.
• Partner with leadership to address discharge delays, barriers, and emerging trends.
• Other Duties as assigned.

Education 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.

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

Certification & Licensure

• 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.

Qualifications

• 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.

Benefits

At Valley Health, we believe everyone is a caregiver, and our goal is to create an environment where our caregivers thrive physically, financially, and emotionally. In addition to a competitive salary, our most popular benefits for full-time employees include:

• A Zero-Deductible Health Plan
• Dental and vision insurance
• Generous Paid Time Off
• Tuition Assistance
• Retirement Savings Match
• A Robust Employee Assistance Program to help with many aspects of emotional wellbeing
• Membership to Healthy U: An Incentive-Based Wellness Program
• A health savings account & flexible spending account for childcare
• life insurance
• short-term and long-term disability
• professional development
• discounts to on-campus dining, and more.

To see the full scale of what we offer, visit valleyhealthbenefits.com.