Social Worker Discharge Planner / Care Coordination Specialist

Key Responsibilities

• Coordinate safe and timely resident discharge planning from admission through discharge.
• Communicate regularly with residents, families, the interdisciplinary team, physicians, therapy, nursing, and community providers.
• Carefully coordinate home health, durable medical equipment, transportation, follow-up appointments, and other post-discharge services.
• Identify and address potential discharge barriers early.
• Participate in interdisciplinary and discharge planning meetings.
• Maintain accurate and timely documentation and discharge tracking.
• Aid in resident and family education regarding discharge plans and next steps.
• Ensure outstanding discharge-related items are followed through to completion.
• Support a positive resident and family experience throughout the transition of care.

Preferred Qualifications

• Experience in skilled nursing, rehabilitation, hospital discharge planning, case management, social services, home health, or healthcare coordination.
• Degree in Social Work, Human Services, Healthcare Administration, Psychology, Sociology, or a related field.
• Strong organizational, communication, and problem-solving skills.
• Ability to manage multiple priorities and meet time-sensitive deadlines.
• Strong computer and documentation skills.
• Proactive, accountable, and comfortable working collaboratively with an interdisciplinary healthcare team.