PT Social Worker Designee - Discharge Planner

Ciena Healthcare; Ovid Township (MI); On-site; USD 21,000 - 29,000; Part time

Benefits offered by this job

Competitive pay

401K with matching funds

Life Insurance

Employee discounts

Tuition Reimbursement

Student Loan Reimbursement

Job summary

CienaHealthcare in Michigan is hiring a Social Services Designee / Discharge Planner for on-site part-time work. You will coordinate safe, timely discharges for skilled nursing residents and support families through the process.

You will collaborate with the interdisciplinary team to identify discharge needs, arrange post-acute services, and ensure compliance with CMS and state regulations. The role offers competitive pay, 401K with matching, life insurance, and tuition reimbursement, with

Qualifications

• High school diploma or GED required.
• 1+ years of discharge planning, case management, or care coordination in healthcare preferred.
• Experience in skilled nursing, post-acute, or long-term care preferred.

Responsibilities

• Meet with resident or responsible party at/after admission and provide ongoing discharge support.
• Collaborate with residents, families, physicians, nursing, therapy, and case management to identify discharge needs and levels of care.
• Arrange post-discharge services including home health, equipment, hospice, outpatient services, transportation, and resources.
• Participate in 72-hour care plan meetings and discharge planning meetings.
• Identify barriers to discharge and communicate with the Social Worker.
• Develop individualized discharge care plans with the team, family, and provider.
• Maintain documentation per CMS/state policies.
• Contribute to QA and Performance Improvement initiatives.

Skills

Discharge planning

Care coordination

Case management

Education

High school diploma/GED

Job description

Posting Details

• Posted on October 23, 2026

Locations

• Showing 1 location 9480 E M 21
  Suite 200
  Ovid, MI 48866, USA
• On-site
• Travel Required : No
• Rate : $18 USD per hour
• Social Services
• Part-Time
• Requisition #: SOCIA003448

Description

The Social Services Designee / Discharge Planner is responsible for coordinating and facilitating safe, timely, and appropriate discharges for residents of the skilled nursing facility. This role supports residents and families through the discharge process by addressing psychosocial needs, coordinating post-acute service, and ensuring compliance with federal, state, and local regulations. The Social Worker collaborates with the interdisciplinary team to address emotional, social, behavioral, and environmental factors that impact resident care, outcomes, and successful transitions.

Join us with an attractive benefits offering:

• Competitive pay
• 401K with matching funds
• Life Insurance
• Employee discounts
• Tuition Reimbursement
• Student Loan Reimbursement

Responsibilities:

• Meet with the resident/responsible party at or shortly after admission and provide ongoing follow-up and support through discharge.
• Collaborate with residents, families, physicians, nursing, therapy, and case management to identify discharge needs and appropriate levels of care.
• Arrange post-discharge services including home health, durable medical equipment, hospice, outpatient services, transportation, and community resources.
• Participate in 72-hour care plan meetings, care conferences, discharge planning meetings, and other meetings as assigned.
• Arrange post-discharge services including home health, durable medical equipment, hospice, outpatient services, transportation, and community resources.
• Identify and communicate potential barriers to discharge to include but not limited to housing, financial, behavioral health or care giver concerns to the Social Worker.
• Develop an individualized discharge care plan in collaboration with the interdisciplinary team, family, and provider, assuring the resident receives the care and services that will meet their needs in the community.
• Conduct assessments, care planning, interventions, referrals, and case management.
• Provide discharge planning, counseling, and support services in coordination with the interdisciplinary team.
• Contributes to the Resident’s assessment (MDS/CAA’s) and the development of a plan of care.
• Assistresidents and families with financial, legal, and community resource referral
• Provide education and counselingregardingtreatment options, health care decision-making, and advance directive forms.
• Facilitate admission process by reviewing advance directives, resident rights, and facility policies.
• Provide grief support and counseling as needed.
• Maintain a current list of community resources andfacilitatereferrals (e.g., home health, hospice, transportation, financial/legal services).
• Maintainaccurate,timely, and compliant documentationin accordance withCMS, state regulations, and facility policies.
• Participate in Quality Assurance and Performance Improvement initiatives as assigned.

Education and/or Experience:

• High school diploma/GED
• One or more years of experience in discharge planning, case management, or care coordination in a healthcare setting preferred.
• Experience in a skilled nursing facility, post-acute, or long-term care environment preferred.
• Working knowledge of discharge planning regulations, resident rights, and post-acute care resources.

Certificate, Licenses, Registrations:

• None

CienaHealthcare

We are a national organization of skilled nursing, subacute, rehabilitative, and assisted living providers dedicated to achieving the highest standards of carein Michigan and Ohio.

We serve our residents with compassion, concern, and excellence, believing that every one of them is a unique person who deserves our best each day that we care for them. Joinus,ifyou have a passion for improving the livesof those around you and working with others who feel the sam

Travel Required

No .

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.