Discharge Planner, Social Services - Full Time First Shift

Valley Health System; Virginia (MN); On-site; USD 36,000 - 55,000; Full time

Benefits offered by this job

Zero-Deductible Health Plan

Dental and vision insurance

Paid Time Off

Tuition Assistance

Retirement Savings Match

EAP program

Wellness Program

Health Savings / FSA

Job summary

Valley Health System in the United States is seeking a Discharge Planner to conduct holistic patient assessments and create individualized discharge plans addressing medical, psychosocial, and community resource needs.

The role coordinates care with clinical partners, leads interdisciplinary care planning, and ensures timely, safe transitions for medically complex patients while supporting families through the discharge process.

Qualifications

• Bachelor’s degree in social work or equivalent required.
• Master’s degree in social work preferred.
• Experience in medical social work preferred.
• Current BLS/CPR certification required.

Responsibilities

• Coordinate discharge plans with clinical partners for complex cases.
• Develop and communicate individualized discharge plans and ensure documentation.
• Lead interdisciplinary care planning meetings and delegate tasks.
• Assist with community referrals and resource navigation for transitions of care.
• Maintain linkage with referral sources for seamless discharge.
• Ensure compliance with Medicare/Medicaid and insurance requirements.

Skills

Verbal communication

Written communication

Multidisciplinary teamwork

Critical thinking

Organization & planning

Time management

Self-directed

Microsoft Word

Windows OS

Education

Bachelor’s degree

Master’s degree preferred

Tools

Microsoft Word

Windows

Job description

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 and Duties

• 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

• 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
• Valley Health also offers a health savings account & flexible spending account for childcare, life insurance, short-term and long-term disability, and professional development.
• In addition, several perks come with working for the largest employer in the region, such as discounts to on-campus dining, and more.

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