Discharge Planner

The Discharge Planner will offer clinical assessment of social, emotional, medical, spiritual and physical needs. The Discharge Planner is able to assess the patient holistically and develop a plan of care based on that assessment. This role will be actively involved with patient assessments and interviews as well as communication with family members. Contribute and/or facilitate a safe and timely discharge of patients who require post-acute care services in coordination with multidisciplinary team. Contribute and/or facilitate the development of a discharge plan of care for high-risk patient populations. Crisis intervention and discharge planning to patients and families with medically/socially complex psychosocial needs. Coordinate the legal process and paperwork involved with protective services, guardianships, adoptions, and advance directives. Assist with the arrangement and follow-up with community resources; in providing a seamless transition utilizing the entire continuum of care; and help to facilitate patients’ movement to the next level of care.

Duties include, but are not limited to

:Identify appropriate community resources and collaborate with patients, families, multi-disciplinary teams, and community agencies to achieve desired patient outcomes. Maintain contact with referral sources until appropriate resources are confirmed

.
Contribute to the development of a goal-directed, age-appropriate plan of care through a multi-disciplinary team process that is prioritized and based on determined medical diagnosis, patient needs, and expected patient outcome

s.
Communicate with patients, families, physicians and health care staff to facilitate coordination of clinical activities and to enhance the effect of the transition from one level of care to another across the continu

um.
Maintain appropriate level of knowledge regarding admission, continued stay, and observation statuses for Medicare, Medicaid, and commercial insurers for all post-acute care services. Promote relationships with commercial and managed care case managers to streamline acceptance proc

ess.
Review and interpret the medical record to determine the appropriateness of patient for post-acute admission to include medical history, tolerance to therapies, potential for improvement, and discharge p

lans.
Ability to recognize, identify, and report signs and symptoms of suspected abuse and/or neglect; making and reporting appropriate referrals to CPS/APS within the specified time frame as required by VA/W

V law.
Provide emotional support and employ therapeutic techniques to cope with chronic, acute, or terminal ill

nesses.
Assist medical staff with identifying decision-makers for patients who are not able to make their own medical decisions and do not have a healthcare surrogate or Medical Power of A

ttorney.
Possess working knowledge of third-party reimbursement processes as well as Medicaid processes/plans for V

A and WV.
Provide substance abuse assessment and resource referral information to patients identified as having potential need for substance abuse

treatment.
Provide information and assistance with completing advance directives and medical power of atto

rney forms.
Attend and participate in discharge pla

nning rounds
Communicate status of plan to care team through appropriate and timely d

ocumentation.
Complete Medicaid screening paperwork for VA and WV prior to patient discharg

e as required.
Assist in the development of safety p

lans as needed.
Coordinate and/or contribute to arranging discharges to post-acute

care facilities.
Assist with and coor

dinate adoptions.
Coordinate and contribute to arranging transportation for di

scharge as needed.
Testify

in court as needed.
Provide on call services as required b

y management at WMC.
Adjust work hours and/or ensuring coverage to meet requirements of patient/family in order to optimize clinical and financial outcomes as they relat

e to discharge plans.
Attend professional meetings, conferences, and workshops relate

d to area

of practice.
EducationMaster’s degree from an accredited social work program

or equiva

lent required
ExperiencePrevious social work experience in a

medical setting desired
Cert

ification & LicensureBLS Certification (Basic Life Support) - American Heart ‘Healthcare Provider’ (HCP) - AHA approved required. New hires must have American Heart Association (AHA) appropriate certification prior to c

ompletion of o

rientation.
QualificationsKnowledgeable in stages of human growth and development for neonate, pediatric, adult

and geriatric populations.
Skills in interpersonal relationships, clinical ass

essment, and group process.
High levels of verbal and w

ritten communication skills.
Ability to interact with other professionals as part

of a multidisciplinary team.
Must be self-directed and have the ability to tolerate frequent interrupti