Discharge Planner

Responsibilities

• Initiate case management services at admission by interviewing individuals to gather history of prior treatment, current services, and existing case management involvement.
• Collect and document comprehensive information on each individual’s needs, strengths, preferences, and access to basic resources.
• Provide ongoing documentation reflecting how identified needs and barriers are addressed throughout the stay.
• Collaborate with external providers and agencies to coordinate care, obtain treatment history, and ensure continuity of services.
• Secure appropriate Releases of Information (ROI) for all communications.
• Maintain consistent communication with individuals and their families/support systems (with consent) to develop and facilitate safe, effective discharge plans with clearly defined supports.
• Identify and address barriers to care, including access to medications, transportation, appointments, financial limitations, and follow-up services.
• Ensure all interventions and resolutions are thoroughly documented.
• Coordinate referrals and admissions to appropriate levels of care, including long-term care facilities, outpatient services, and community support programs.
• Assist with insurance initiation (e.g., through Hope Dealers) when needed to support placement.
• Arrange and confirm follow-up appointments prior to discharge, ensuring individuals are informed of all aftercare plans, including appointment details, locations, and any open-access hours.
• Prepare, complete, and review interdisciplinary discharge summaries, ensuring all required elements are included (clinical benchmarks, health conditions, referrals, community resources, follow-up care, and 988/crisis information).
• Ensure all documentation is signed, finalized, and properly filed.
• Review discharge plans with individuals prior to discharge, providing a clear overview of aftercare services and expectations.
• Communicate suicide risk status (high/moderate) and other critical clinical information to receiving providers to ensure safe transitions of care.
• Coordinate and arrange transportation for individuals upon discharge, and assist with transport when necessary.
• Maintain accurate and up-to-date records in the electronic health system (e.g., Netsmart), including verified contact information and completed ROI documentation for follow-up communication.
• Conduct follow-up outreach within 7 days of discharge (minimum of three attempts), with additional documentation requirements for individuals identified as high or moderate suicide risk.
• Maintain a log of follow-up attempts to support continuity of care.
• Absorb and respond to Level of Care (LOC) submissions, service orders, and suicide risk alerts as required.
• Ensure all treatment plan components are completed and supported by appropriate, timely progress notes in the medical record.
• Provide supervision and support to individuals on the unit as needed, including assisting with admissions and searches when necessary.
• Maintain and update resource lists at least annually to ensure accurate referral options.
• Complete required surveys (e.g., NSH), including initiating intake portions and coordinating completion of follow-up components with community providers.

Requirements

• A High School Diploma/GED Equivalent.
• A Valid Georgia Driver’s License.
• Effective verbal and written communication skills.
• Strong interpersonal skills and the ability to work effectively with diverse communities.
• The ability to work independently and in collaboration with others.
• Experience with Microsoft 365 Office Products.

Qualifications

• A Bachelor's degree in a relatable field is preferred but not required.

Skills

• Background in social work and case management is a plus.

Benefits

As a member of our team, you will enjoy our total rewards package to help secure your financial future and preserve your health and well-being, including:

• Medical, Dental & Vision Plan Options!
• A Generous Paid-Time Off Policy with Flexibility.
• A 401(k) Plan with Company Match!
• Short- & Long-Term Disability Plans!
• Access to our Employee Assistance Program (EAP)!
• Paid Training Time!
• Opportunities for Career Growth & Advancement!

… And so much more!

At this time, CSB of Middle Georgia will not sponsor a new applicant for employment authorization for this position.

** Final pay rate will be dependent on a combination of qualifications such as experience and education. **