Discharge Planner, Social Services - Full Time First Shift

Valley Health; Winchester (VA); On-site; USD 55,000 - 83,000; Full time

Benefits offered by this job

Zero-Deductible Health Plan

Dental and vision insurance

Paid Time Off

Tuition Assistance

Retirement Savings Match

Employee Assistance Program

Wellness Program

On-campus dining discounts

Job summary

Valley Health is seeking a Discharge Planner to assess patients and develop individualized care plans addressing social, emotional, medical, spiritual, and physical needs. You will coordinate safe, timely discharges for complex cases and provide psychosocial support throughout transitions of care.

You will work with interdisciplinary teams, educate families on resources, and navigate guardianship, advance directives, and protective services as required.

Qualifications

• Bachelor's degree in social work required.
• Master's degree in social work preferred.
• BLS certification (Healthcare Provider) required prior to orientation.
• Experience in medical social work preferred.

Responsibilities

• Coordinate discharge plans with interdisciplinary teams for medically and socially complex patients.
• Educate patients and families on community resources and referrals for continuity of care.
• Provide crisis intervention and psychosocial support for patients and families.
• Assist with guardianship, advance directives, and protective services where needed.
• Ensure compliance with Medicare/Medicaid and insurance requirements for post-acute care.
• Document plans and communicate with care teams to support transitions of care.

Skills

Verbal communication

Written communication

Team collaboration

Critical thinking

Time management

Crisis intervention

Interpersonal skills

Education

Bachelor's degree in social work

Master's degree in social work preferred

Tools

Windows

Microsoft Word

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.DepartmentSOCIAL SERVICES - 207170Worker Sub TypeRegularWork ShiftFirst Shift (United States of America)Pay Range$26.45 - $39.68Job DescriptionThe 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.Responsibilities and DutiesCoordinate 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.EducationBachelor’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.ExperiencePrevious social work experience in a medical setting is preferred.Certification & LicensureBLS 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.QualificationsAbility 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.BenefitsAt 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 PlanDental and vision insuranceGenerous Paid Time OffTuition AssistanceRetirement Savings MatchA Robust Employee Assistance Program to help with many aspects of emotional wellbeingMembership to Healthy U: An Incentive-Based Wellness ProgramValley 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 .