Social Worker Designee - Discharge Planner

Ciena Healthcare; Michigan; On-site; USD 52,000 - 68,000; Full time

Benefits offered by this job

Competitive pay

Medical, dental, and vision insurance

401K with matching funds

Life Insurance

Employee discounts

Tuition Reimbursement

Student Loan Reimbursement

Job summary

CienaHealthcare in Michigan is seeking a Social Services Designee / Discharge Planner to coordinate safe, timely discharges for residents in a skilled nursing facility. You will collaborate with an interdisciplinary team to address psychosocial needs and coordinate post-acute services to ensure compliant transitions.

Join our team for competitive pay and a comprehensive benefits package including health, retirement, and tuition assistance.

Qualifications

• High school diploma or GED required.
• 1+ years of discharge planning, case management, or care coordination experience 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.

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.
• Identify and communicate potential barriers to discharge to include housing, financial, behavioral health or caregiver 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.
• Assist residents and families with financial, legal, and community resource referral.
• Provide education and counseling regarding treatment 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 and facilitate referrals (e.g., home health, hospice, transportation, financial/legal services).
• Maintain accurate, timely, and compliant documentation in accordance with CMS, state regulations, and facility policies.
• Participate in Quality Assurance and Performance Improvement initiatives as assigned.

Skills

Discharge planning

Care coordination

CMS regulations knowledge

Interdisciplinary teamwork

Communication skills

Education

High school diploma/GED

Job description

Job Details

Posting Details

• Posted on September 2, 2026

Locations

• Showing 1 location Ely Manor
• 1200 Ely St
• Allegan, MI 49010, USA
• Travel Required : No
• Social Services
• Full-Time
• Requisition #: SOCIA003307

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
• Medical, dental, and vision insurance
• 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. Join us, if you have a passion for improving the lives of those around you and working with others who feel the same.

IND123

Travel Required

No.

Onsite 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.