Rehab Discharge & Care Coordination Specialist

St. Luke’s University Health Network; Bethlehem (Northampton County); On-site; USD 70,000 - 90,000; Full time

Job summary

St. Luke’s University Health Network is seeking a discharge planning professional in the rehabilitation setting to identify psychosocial barriers, coordinate care, and plan timely discharges.

You will work closely with patients, families, and the interdisciplinary team to develop individualized discharge plans and ensure smooth transitions. Responsibilities include ongoing discharge assessments, documentation, and collaboration to connect patients with community resources and durable medical

Qualifications

• MSW, RN (BSN preferred) or related field equivalent.
• Two to five years clinical healthcare experience, rehabilitation setting preferred.
• Knowledge of discharge planning, care management, and regulatory guidelines (Medicare/CARF/JCAHO).

Responsibilities

• Performs admission review on rehabilitation patients to identify psycho-social barriers, interventions, and discharge planning needs.
• Assesses discharge planning needs, mitigates barriers, and facilitates timely and safe discharge.
• Completes documentation.
• Collaborates with patient, family, and interdisciplinary team to design discharge plans.
• Maintains contact with patient/family at least three times weekly about rehab progress and plans.
• Participates in daily stand-up meetings with the interdisciplinary team and weekly meetings for all patients.
• Arranges services prior to discharge to meet patient needs and reduce readmission, including community, state, federal resources, and DME acquisition.
• Provides education to patients and families about adaptation to diagnosis and discharge planning.
• Acts as a resource to staff regarding discharge options, community resources, and regulatory issues.

Education

MSW, RN (BSN preferred), OR Masters in a related field of physical, occupational, or speech therapy

Job description

St. Luke’s University Health Network is seeking a discharge planning professional in the rehabilitation setting to identify psychosocial barriers, coordinate care, and plan timely discharges.

You will work closely with patients, families, and the interdisciplinary team to develop individualized discharge plans and ensure smooth transitions. Responsibilities include ongoing discharge assessments, documentation, and collaboration to connect patients with community resources and durable medical