Discharge Planning Lead — Care Coordination & Transitions

UPMC; Carlisle (Cumberland County); On-site; USD 60,000 - 90,000; Part time

Job summary

UPMC Carlisle is recruiting a Discharge Plan Manager to coordinate post-discharge needs and act as the financial steward for the hospital. The role focuses on creating an optimal discharge plan that uses hospital resources efficiently and ensures timely transitions from inpatient care.

You will assess patient needs, collaborate with the care team, engage patients and families, and coordinate post-hospital services to support safe, effective outcomes.

Qualifications

• Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes.
• Take patient/family/caregiver level of health literacy into consideration.
• Evaluate patient/family/caregiver level of understanding and engagement with progress toward goals and incorporate findings into the plan of care.
• Balances resources with patient preferences and goals of care.
• Evaluate the potential impact of social determinants of health that may elevate the risk of a poor transition.

Responsibilities

• Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes.
• Complete detailed assessment on every patient in order to establish understanding of medical and social factors, determine patient’s capacity for self-care, identify support systems, outline barriers to discharge, and determine likeliness of requiring post-hospital services and the availability of such services.
• Facilitate teams to develop and execute safe and efficient discharges. Maintain knowledge about area resources and their capabilities and capacities as well as various types of service providers available.
• Engage in clear communication with the patient/member/caregivers as well as the interdisciplinary care team in order to develop discharge plans. Serve as a liaison between the patient and the care team.
• Serve as a contact between hospitals and post-hospital care facilities as well as the physicians who provide care in either or both of these settings.
• Recognize and demonstrate shared accountability in development of a discharge plan with the patient/member/caregiver as well as with team members to ensure optimal outcomes.
• Align practice with the mission, vision, and values of the organization. Adheres to ethical standards and codes of conduct of applicable professional organization and UPMC.
• Advocate on behalf of patient/family/caregivers for services access and for the protection of the patient's health, well-being, safety, and rights.
• Manage cost of care with the benefits of patient safety, clinical quality, risk and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes.
• Embrace and incorporate innovation and technology to improve collaboration and patient outcomes. Document care in patient medical chart.
• Provide staff orientation and mentoring as appropriate.

Job description

UPMC Carlisle is recruiting a Discharge Plan Manager to coordinate post-discharge needs and act as the financial steward for the hospital. The role focuses on creating an optimal discharge plan that uses hospital resources efficiently and ensures timely transitions from inpatient care.

You will assess patient needs, collaborate with the care team, engage patients and families, and coordinate post-hospital services to support safe, effective outcomes.