Remote Discharge Planner – Hospital Care Transitions

Millennium Physician Group; Tallahassee (FL); Remote; USD 53,000 - 79,000; Full time

Benefits offered by this job

3 weeks PTO

8 paid holidays

Medical

Dental

Vision

Employer Paid Basic Life & Short Term

401(k) with match

Employee Wellness

Other Employee Discount programs like:

Dependent Care FSA

Voluntary Life

Long Term Disability

Critical Illness

Pet Insurance

Job summary

Millennium Physician Group in Florida is seeking a Discharge Planner I, Hospitalists to coordinate discharge planning and post-acute services for hospitalized patients. You will work with physicians, nurses, case managers and families to ensure safe, timely transitions and regulatory compliance.

Responsibilities include assessing needs, developing individualized plans, coordinating services, educating patients and caregivers, and reducing readmissions.

Responsibilities

• Assess patients' discharge planning needs through review of medical records, interdisciplinary collaboration, patient interviews, and evaluation of clinical, functional, psychosocial, and environmental factors affecting post-discharge care.
• Develop and coordinate individualized discharge plans that align with physician orders, patient goals, payer requirements, and available community resources.
• Collaborate with hospitalists, nursing staff, case managers, therapists, pharmacists, social workers, and ancillary departments to coordinate timely, safe, and effective patient discharges.
• Arrange post-acute services including home health, skilled nursing facilities, rehabilitation services, durable medical equipment, hospice, outpatient therapies, transportation, and community-based resources as appropriate.
• Educate patients and caregivers regarding discharge instructions, medications, follow-up appointments, disease management, warning signs requiring medical attention, and available community resources.
• Identify barriers to discharge including insurance authorization delays, transportation needs, caregiver limitations, equipment availability, housing concerns, or social determinants of health, and coordinate appropriate interventions.
• Communicate with primary care providers, specialists, post-acute providers, payers, and external agencies to facilitate continuity of care and reduce avoidable readmissions.
• Document discharge planning assessments, care coordination activities, referrals, patient education, and transition plans accurately within the electronic health record in accordance with organizational standards and regulatory requirements.
• Monitor discharge timelines, transition metrics, and assigned patient caseloads while supporting organizational goals related to length of stay, readmission reduction, patient satisfaction, and quality outcomes.
• Participate in interdisciplinary rounds, quality improvement initiatives, patient safety activities, and care transition programs that improve discharge processes and patient outcomes.
• Maintain knowledge of applicable regulatory requirements, Medicare Conditions of Participation, payer guidelines, post-acute care resources, and evidence-based transition-of-care practices.

Job description

Millennium Physician Group in Florida is seeking a Discharge Planner I, Hospitalists to coordinate discharge planning and post-acute services for hospitalized patients. You will work with physicians, nurses, case managers and families to ensure safe, timely transitions and regulatory compliance.

Responsibilities include assessing needs, developing individualized plans, coordinating services, educating patients and caregivers, and reducing readmissions.