In support of patient progression practice, provides patient/family focused interventions to support timely discharge outcomes. Facilitates the pace of the case for real time completion of concrete interventions identified in the discharge plan. Using a variety of modalities carries out discharge plan recommendations for the alleviation or resolution of social financial and emotional problems related to illness, healthcare and rehabilitation allowing a timely transition of a patient from the hospital to the most appropriate next level of care.
Activities include such things as preparing information to facilitate a patient’s discharge/transfer, arranging equipment and transportation, and discussing plans with the patient and family. Documents her/his work in the patients’ medical record per department requirements.

• Identifies patient and/or families requiring coordination of continuing care or community support through collaboration with case managers, social workers and other members of the care team. Reviews medical records, attends rounds, and responds to patients needs. Assists the case manager and/or social worker with implementing continuing care plans. Applies knowledge based on professional experience.
• Under the direction of a Case Manager and/or Social Worker assists in the facilitation of an appropriate discharge for her/his patients in accordance with the patient’s medical readiness and expected needs. Assists in coordinating a patients discharge/transition to settings such as skilled nursing homes, home with home health, patients with medical equipment, etc.
• Prepares the patient and/or family for discharge by providing an explanation of the plan and what the patient/family can expect.
• When needed for a safe, expeditious, effective discharge engages other members of the care team to have the patients/families questions answered, and assures there is adequate resolution.
• Assures that a discharge is facilitated in accordance with regulatory requirements, patient/family choice, financial resources, and third party payer requirements.
• Places referrals to multiple agencies reflecting the recommended level of care from the Care Management team.
• Assists with a safe and effective handover to the next level of care by working closely with both hospital staff and external agency liaisons and care navigators.
• Complete screenings for patients regarding financial, psychosocial, physical, and medical needs to determine long term care service supports
• Coordinate with outside agencies and community members to ensure continuity of services after an LTSS (UAI) screening has been completed
• Determine financial supports and referring patients/family members to local DSS or inpatient social workers to complete Medicaid applications or financial screenings
• Assess mental health needs prior to patients discharging to skilled nursing facilities to ensure appropriate services at time of discharge (understanding the need for a Level II PASRR report)
• Documents his/her work in the medical record, meeting the requirements of the organization and department. Submits reports as required by management on things such as productivity, patient progression barriers or other focused studies.
• Enhances the quality of patient care by complying with policies, procedures and the quality measures of the hospital and department. Identifies and reports any problems, conflicts, trends, or other potential issues to appropriate administrative staff.
• In addition to the above job responsibilities, other duties may be assigned.

Position Compensation Range: $22.39 - $35.82 Hourly
MINIMUM REQUIREMENTS
Education: Bachelor's degree required, Bachelors of Social Work preferred.
Experience: One year in healthcare or similar setting, hospital setting preferred
Licensure: None
PHYSICAL DEMANDS
Job requires sitting for prolonged periods, standing/traveling or use of assistive and climbing (stairs, steps). Proficient communicative, auditory and visual skills; Attention to detail, hear, speak, see, distinguish colors, read, ability to write legibly; Ability to lift/push/pull < 20lbs. May be exposed to chemicals, blood/body fluids and infectious disease.
The University of Virginia, i ncluding the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician’s Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff. We believe diversity is excellence expressing itself through every person's perspectives and lived experiences. We are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.
Position Compensation Range: $22.39 - $35.82 Hourly
MINIMUM REQUIREMENTS
Education: Bachelor's degree required, Bachelors of Social Work preferred.
Experience: One year in healthcare or similar setting, hospital setting preferred
Licensure: None
PHYSICAL DEMANDS
Job requires sitting for prolonged periods, standing/traveling or use of assistive and climbing (stairs, steps). Proficient communicative, auditory and visual skills; Attention to detail, hear, speak, see, distinguish colors, read, ability to write legibly; Ability to lift/push/pull < 20lbs. May be exposed to chemicals, blood/body fluids and infectious disease.