Discharge Plan Manager, RN or Social Worker

Responsibilities

• Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes.
• Evaluate patient/family/caregiver level of health literacy and understanding, incorporating findings into the plan of care.
• Balances resources with patient preferences and goals of care.
• Evaluate the potential impact of social determinants of health that may elevate the risk of a poor transition.
• Complete detailed assessment on every patient in order to establish understanding of medical and social factors, determine patient's capacity for self-care, identify support systems, outline barriers to discharge, and determine likeliness of requiring post-hospital services and the availability of such services.
• Continually reassess discharge plan for factors that may affect continuing care needs or the appropriateness of the discharge plan.
• Facilitate teams to develop and execute safe and efficient discharges.
• Maintain knowledge about area resources and their capabilities and capacities as well as various types of service providers available.
• Ensure appropriate arrangements for post-hospital care will be made before discharge and work to avoid unnecessary delays in discharge.
• Integrate patients' goals, the health care team's assessment, risks and available resources in order to develop and coordinate a successful transition plan.
• Engage in clear communication with the patient/member/caregivers as well as the interdisciplinary care team in order to develop discharge plans.
• Serve as a liaison between the patient and the care team.
• Actively collaborate with the attending practitioner, caregivers, and other members of the multidisciplinary team to coordinate an individualized plan of care.
• Incorporate discipline-specific recommendations, test results, outstanding orders into discharge plan and monitor/revise and respond to the progression of discharge milestones.
• Serve as a contact between hospitals and post-hospital care facilities as well as the physicians who provide care in either or both of these settings.
• Recognize and demonstrate shared accountability in development of a discharge plan with the patient/member/caregiver as well as with team members to ensure optimal outcomes.

Qualifications

• RN: Diploma or associate degree in nursing and active Registered Nurse license. At least one year of experience in discharge planning/care coordination required.
• Social Worker (SW): Bachelor's degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of those being served required. Master's degree preferred. At least one year of experience in discharge planning/care coordination required.

Benefits

• A $10,000 sign-on bonus for eligible roles with a two-year commitment.
• A designated career ladder designed to support career advancement, with two tracks to support both nurses and social workers.
• Up to 5 1/2 weeks of paid time off and 7 paid holidays.
• $6,000/year in tuition assistance to help you get where you want to be.
• And much more!