Discharge Planning Specialist - Social Work Consultant II

NALHE; Decatur (GA); On-site; USD 65,000 - 85,000; Full time

Job summary

Kaiser Permanente in Decatur, GA is seeking a Medical Social Worker II to coordinate discharge planning for hospital patients, ensuring smooth transitions to the appropriate care setting. You will collaborate with care teams, identify post-discharge needs, and connect patients and families with Kaiser and community resources.

The role emphasizes biopyschosocial assessment, advocacy, documentation, and timely placement, in line with state and federal regulations.

Responsibilities

• Oversee or participate in individual discharge plans to transition members to appropriate care after inpatient stay.
• Partner with multidisciplinary teams to identify needs and execute discharge plans.
• Discuss care options proactively, including Kaiser resources and community/government resources.
• Collaborate with disciplines to assess, plan, and provide biopsychosocial services.
• Coach members pre-discharge to advocate for themselves within Kaiser and the community.
• Ensure members and caregivers are updated with approved discharge plans.
• Review, evaluate, and prioritize referrals written and oral.
• Maintain documentation, records, and data for discharge planning.
• Complete required documents in a timely manner.
• Liaise with the Post-Acute Team for timely Kaiser member placements.
• Serve as liaison between patient and Kaiser to ensure continuity of care.
• Identify appropriate levels of care and facilities for referred patients.
• Obtain placements when applicable.
• Coordinate with Kaiser and community resources to meet goals.
• Provide information and referrals to community resources as requested.
• Coordinate information exchange among Kaiser, families, members, and facilities.
• Determine application of Kaiser/Medicare benefits for care transitions.
• Coordinate active insurance coverages for care transitions and inform facilities of benefits.
• Participate in Utilization Management/Quality Assurance activities.
• Assist in coordinating communication between regional offices, clinics, hospitals, and field staff.
• Remain knowledgeable of contract benefits and relevant regulations affecting managed care.
• Work cross-functionally to meet organizational goals.
• Work with referral sources to clarify and complete clinical and psychosocial information.
• Provide consulting to Kaiser Permanente Acute Care Centers and related units as needed.
• Escalate issues and barriers timely and appropriately.
• Perform other related duties as necessary.

Job description

Kaiser Permanente in Decatur, GA is seeking a Medical Social Worker II to coordinate discharge planning for hospital patients, ensuring smooth transitions to the appropriate care setting. You will collaborate with care teams, identify post-discharge needs, and connect patients and families with Kaiser and community resources.

The role emphasizes biopyschosocial assessment, advocacy, documentation, and timely placement, in line with state and federal regulations.