What are the responsibilities and job description for the Discharge Planning Associate - Clinical Care Coordination position at UPMC?
Full-Time Discharge Planning Associate – Clinical Care Coordination (UPMC Hamot)
UPMC Hamot is seeking a Full-Time Discharge Planning Associate to join our dedicated Clinical Care Coordination team. In this role, you will help support safe, timely, and effective transitions of care for hospitalized patients, ensuring they receive the resources and services needed following discharge.
About the Role
The Clinical Care Coordination team partners with patients, families, physicians, nurses, and other members of the interdisciplinary care team to develop individualized discharge plans once patients are medically stable. As a Discharge Planning Associate, you will work directly with patients to assess discharge needs, identify appropriate post-acute care options, and facilitate transitions across the continuum of care.
This position collaborates with internal departments, external agencies, community resources, and insurance providers to coordinate services, obtain necessary authorizations, and help ensure continuity of care after hospitalization.
Our team is committed to helping patients achieve a safe and successful transition from the hospital. Through collaboration, communication, and advocacy, we work closely with patients, families, and care teams to overcome barriers and connect patients with the resources they need to thrive after discharge.
Schedule
- Shift options include 7:30 a.m. to 4:00 p.m. (8-hour shifts) or 7:30 a.m. to 6:00 p.m. (10-hour shifts)
- Required to work two weekend days within a six-week period
Sign-On Bonus
- This position is eligible for a $6,000 Sign-On Bonus for qualified candidates with a two-year employment commitment.
Why Join Clinical Care Coordination at UPMC Hamot?
Clinical Care Coordination plays a critical role in supporting positive patient outcomes, enhancing the patient experience, and ensuring seamless transitions across the healthcare continuum. Team members have the opportunity to make a meaningful impact every day by helping patients navigate complex healthcare needs and access the services necessary for their continued recovery and well-being.
Candidates with an RN license or a bachelor's degree in social work (BSW) are highly preferred.
Title and salary will be determined based upon education and nursing experience.
Responsibilities:
- Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes.
- Take patient/family/caregiver level of health literacy into consideration.
- Evaluate patient/family/caregiver level of understanding and engagement with the progress toward goals and incorporate 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 milestone.
- 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.
- Align practice with the mission, vision, and values of the organization.
- Adheres to ethical standards and codes of conduct of applicable professional organization and UPMC.
- Maintain clinical knowledge of and ensures compliance with regulatory requirements.
- Advocate on behalf of patient/family/caregivers for services access and for the protection of the patient's health, well-being, safety, and rights.
- Manage cost of care with the benefits of patient safety, clinical quality, risk and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes.
- Embrace and incorporate innovation and technology to improve collaboration and patient outcomes.
- Document care in patient medical chart.
- Provide staff orientation and mentoring as appropriate.
Salary : $1,000 - $1,000,000