Expert Discharge Plan Manager (RN or Social Worker) UPMC Presbyterian

UPMC Presbyterian is seeking an Expert Discharge Plan Manager to support the Clinical Care Coordination and Discharge Planning department. This role focuses on ensuring safe and smooth transitions for patients to their homes or other care settings, collaborating with healthcare providers, patients, and families to create personalized discharge plans.

Responsibilities

• Performs in accordance with system-wide competencies/behaviors and other duties as assigned.
• Advocates on behalf of patients, families, and caregivers for service access and protection of health, well-being, safety, and rights.
• Aligns practice with the mission, vision, and values of the organization.
• Adheres to ethical standards and codes of conduct of professional organizations and UPMC.
• Maintains clinical knowledge and ensures compliance with regulatory requirements.
• Assists in operational activities for the department, including staff orientation, mentoring, and addressing other issues.
• Completes detailed assessments of patients to understand medical and social factors, self-care capacity, support systems, discharge barriers, and post-hospital service needs.
• Continually reassesses discharge plans for factors affecting continuing care needs or plan appropriateness.
• Demonstrates expertise in discharge planning functions and incorporates innovation and technology to improve collaboration and outcomes.
• Documents care in the inpatient medical chart.
• Engages in clear communication with patients, caregivers, and the interdisciplinary care team to develop discharge plans.
• Serves as a liaison between the patient and care team, collaborating with practitioners, caregivers, and multidisciplinary team members to coordinate individualized care plans.
• Incorporates discipline-specific recommendations, test results, and outstanding orders into the discharge plan, monitoring and revising as needed.
• Facilitates teams to develop and execute safe and efficient discharges.
• Maintains knowledge of area resources, their capabilities, and capacities, as well as various service providers.
• Ensures appropriate post-hospital care arrangements are made before discharge to avoid unnecessary delays.
• Integrates patients' goals, team assessments, risks, and available resources to develop and coordinate successful transition plans.
• Identifies clinical, psychosocial, historical, financial, cultural, and spiritual needs to guide planning and attain optimal outcomes.
• Considers patient/family/caregiver health literacy in planning and evaluates their understanding and engagement with care goals.
• Balances resources with patient preferences and goals of care.
• Evaluates the impact of social determinants of health on transition risks.
• Leads process improvement initiatives.
• Manages care costs while prioritizing patient safety, clinical quality, risk, and satisfaction to ensure optimal outcomes.
• Demonstrates shared accountability in discharge planning with patients, caregivers, and team members.
• Serves as a contact between hospitals, post-hospital care facilities, and physicians.

Discharge Planning Experience

• Coordinates clinical care needs from inpatient to outpatient settings, post-discharge facilities to home or assisted living, or outpatient resources.
• Includes insurance authorizations (medication, transportation, alternate level of care), coordination of care transitions (skilled nursing, inpatient rehab, home care), initiating hemodialysis, coordinating hospice care, and connecting patients to regional outpatient resources.

Requirements

Nurse Track

• BSN required.
• RN License required.
• CCM/ACM or other nursing certification required.

Non-Nurse Track

• MSW or master’s degree in a health and human services field required.
• LSW, LCSW, or education-appropriate license required.
• CCM/ACM or other social work certification required.

Licensure, Certifications, and Clearances

• Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR).
• Act 33, Act 34, and Act 73 FBI Clearance (with renewal).

Benefits

• $10,000 sign-on bonus for eligible roles with a two-year work commitment.
• Designated career ladder supporting career advancement for both nurses and social workers.
• Flexible schedule options.
• Up to 5 ½ weeks of paid time off and 7 paid holidays.
• $6,000/year in tuition assistance.