Senior Care Transition Specialist: Discharge Planning

Forward Healthcare Group; Pearland (TX); On-site; USD 60,000 - 75,000; Full time

Job summary

Thrive Rehabilitation of Pearland is seeking a dedicated Discharge Planner to join our interdisciplinary care team. You will coordinate safe transitions for residents returning to the community or other post-acute settings, working closely with physicians, therapists, nurses, and case managers.

The ideal candidate has a relevant degree, 1–2 years in discharge planning or social work, strong Medicare/Medicaid knowledge, excellent communication, and proficiency with PointClickCare.

Qualifications

• Bachelor’s degree in Social Work, Nursing, Healthcare Administration or related field is preferred.
• 1–2 years of discharge planning, case management or social work experience in SNF, hospital or long-term care.
• Strong knowledge of Medicare/Medicaid and local community resources for seniors.
• Proficiency with Electronic Health Record (EHR) systems (e.g., PointClickCare).

Responsibilities

• Coordinate safe transitions to home, home health, assisted living, or hospice.
• Collaborate with physicians, therapists, nursing staff, and case managers to track progress and set discharge timelines.
• Arrange post-discharge services: DME, home care, transportation, and medication delivery.
• Lead discharge planning conferences with residents and families to discuss options and resources.
• Complete Social Services assessments and discharge paperwork per state/federal guidelines and facility policies.
• Coordinate with insurance payors to secure authorizations for post-discharge services.

Skills

Verbal and written communication

Crisis intervention

Empathy

PointClickCare

Education

BSW

BSN/RN

Healthcare Administration

Tools

PointClickCare

Job description

Thrive Rehabilitation of Pearland is seeking a dedicated Discharge Planner to join our interdisciplinary care team. You will coordinate safe transitions for residents returning to the community or other post-acute settings, working closely with physicians, therapists, nurses, and case managers.

The ideal candidate has a relevant degree, 1–2 years in discharge planning or social work, strong Medicare/Medicaid knowledge, excellent communication, and proficiency with PointClickCare.