Discharge Planning Social Worker – Seamless Transitions

Ciena Healthcare; Michigan; On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Competitive pay

Medical, dental, vision insurance

401K with matching funds

Life Insurance

Employee discounts

Tuition Reimbursement

Student Loan Reimbursement

Job summary

Ely Manor, a Ciena Healthcare facility in Michigan, seeks a Social Services Designee / Discharge Planner to coordinate safe, timely discharges. You will support residents and families, address psychosocial needs, and ensure compliance with regulations while collaborating with the interdisciplinary team.

Responsibilities include discharge meetings, arranging post-acute services, and developing individualized care plans to meet community needs.

Qualifications

• High school diploma or GED required.
• 1+ years in discharge planning, case management, or care coordination in healthcare preferred.

Responsibilities

• Meet with resident or responsible party at admission and provide ongoing discharge support.
• Collaborate with residents, families, physicians, nursing, therapy, and case management to plan discharge needs.
• Arrange post-discharge services including home health, DME, hospice, transportation and community resources.
• Participate in 72-hour care plan meetings and discharge planning conferences.
• Identify barriers to discharge related to housing, finances, behavioral health or caregiver concerns.
• Develop individualized discharge care plans with the team to meet community needs.
• Conduct assessments, care planning, referrals, and case management.
• Provide discharge planning counseling and support in coordination with the team.
• Contribute to resident assessments and plan of care; assist with financial and resource referrals.
• Educate residents and families on treatment options and advance directives.

Skills

Discharge planning

Care coordination

Healthcare experience

Education

High school diploma/GED

Job description

Ely Manor, a Ciena Healthcare facility in Michigan, seeks a Social Services Designee / Discharge Planner to coordinate safe, timely discharges. You will support residents and families, address psychosocial needs, and ensure compliance with regulations while collaborating with the interdisciplinary team.

Responsibilities include discharge meetings, arranging post-acute services, and developing individualized care plans to meet community needs.