Care Manager - Discharge Planner

Copley Hospital, located in Morrisville/Stowe VT, is seeking a Care Manager- Discharge Planner to join our team. This role is a core member of the hospital care team and leads discharge planning through partnerships with caregivers, internal and external providers, patients, families, and communities. The position contributes to transforming the healthcare system to meet demands for safety, quality, patient-centered, and affordable care.

About the role

This position coordinates the interdisciplinary process throughout the continuum of care to ensure care coordination, communication, and collaboration with patients, families, providers, ancillary services, and community partners. Discharge planning begins at or prior to admission and is reassessed during hospitalization. The role involves intervening to enhance patient quality outcomes and serving as a patient advocate. This is a Per Diem position with Full-Time and Part-Time options available.

Responsibilities

• Leads the discharge planning process, linking patients and families with appropriate institutional or community resources post-discharge, starting at admission or prior to planned hospitalization.
• Utilizes key elements for evidence-based discharge planning:
  • Includes patients and families as full partners in the discharge process.
  • Discusses five key areas to prevent problems at home.
  • Describes post-discharge life, reviews medications, highlights warning signs, and explains the care plan, including test results.
  • Makes follow-up appointments and educates patients and families using plain language about conditions, the discharge process, and next steps.
  • Assesses how well doctors and nurses explain diagnoses, conditions, and next steps using teach-back strategies.
  • Listens to and honors patient and family goals, preferences, observations, and concerns.
• Supports Care Management and Utilization Review roles and functions:
  • Serves as a clinical resource and contributes expertise to facilitate care goals.
  • Collaborates with insurance companies, social work, and other departments when patient care needs exceed health benefit coverage.
  • Assesses patients to determine appropriateness of admission, observation status, continued hospitalization, and level of care.
  • Maintains knowledge of Medicare-Medicaid guidelines and coding specifics.
  • Communicates with physicians to ensure compliance with guidelines and with third-party payers.
  • Provides clinical information, including patient status, plan of care, and discharge disposition as requested.
  • Utilizes MCG, Intensity of Service, and Severity of Illness criteria to determine eligibility for acute care and observation services.
• Performs concurrent and retrospective monitoring and analysis of care processes, identifying and recommending improvements.
• Collaborates with nursing, physicians, and the Quality Improvement department.

Requirements

• Associate Degree in Nursing.
• Minimum of three (3) years of relevant clinical experience, including discharge planning, utilization, and quality management skills.
• Experience with chart reviewing, auditing, and data extraction and analysis.
• RN License in Vermont in good standing.

Skills

• Strong clinical, leadership, and computer skills.
• Able to establish and maintain strong working relationships.
• Self-directed, assertive problem-solving, and effective assessment and planning skills.
• Excellent written and oral communication skills.
• Ability to champion and build interdisciplinary teams.

Pay

$33–37/hour. The posted salary range reflects compensation for candidates with limited experience. An offer may vary based on factors such as experience, education, skills, internal equity, and market data. An offer of employment may be outside of the posted range based on those factors.