The Discharge Planner coordinates patient transition along the healthcare continuum through assessments, referrals and interdisciplinary planning.  Coordinates the post-hospitalization services as outlined in the patient’s transition plan.  The Discharge Planner provides the necessary focus on the patient’s psycho-social, financial, and transition needs in order to promote optimal outcomes including reducing related and unplanned re-hospitilization.  Refers patients to appropriate community services and resources.  Alerts members of the interdisciplinary team to psycho-social and financial issues risk factors.  The Discharge Planner applies the use of data in his/her practice; identifying where to focus efforts, the measurement of progress towards identified outcomes, and as an educational tool.  This individual possesses excellent interpersonal, negotiation, and influence skills and works to effect positive practice changes that lead to improved value in patient care delivery.

Our values of Excellence, Empathy, Integrity and Accountability are essential to exceed our customers’ expectations. At Reid, we look for individuals who believe in our core values and demonstrate a genuine desire to make a positive impact to those we serve.  We take pride in employing people who show up every day with a commitment to these values along with our mission and vision. We are one team working toward a common goal of providing outstanding customer care and service to our communities. If you have a calling to serve and are looking for meaningful and purposeful work, Reid Health is the place for you.

To lead our communities to well-being, one person at a time. It is not just what we do – it is who we are.

• Works collaboratively with the Case Manager and interdisciplinary team to identify and establish patient transition plans, and coordinates a timely safe patient discharge/transfer.
• Coordinates post-hospitalization services for patients as identified by the interdisciplinary team.
• Understands the patient’s planned course of treatment to the degree necessary in order to anticipate “transition readiness” and coordinate a timely discharge/transfer.
• Start referrals timely so payer authorization process can begin early to avoid delays, as applicable.
• Collaborates with the patient/ family in the selection and making of post-hospitalization care arrangements; Offers patients a choice of vendors;. Discloses which vendors have a financial relationship with the hospital; Documents both; Follows Transition Management Policy
• Keeps the patient/ family, Case Manager, and healthcare team well informed.
• Communicates the relevant information to the agency/facility that will assume responsibility for continuing care after the patient’s release and documents as such.
• Documents all transition coordination activity and interventions in medical record.
• Makes referrals to other department services as applicable to the patient’s needs in order to expedite a safe and timely discharge.
• Trends, analyzes, and reports outcomes, clinical process and variance data to appropriate audiences.
• Participates in process and outcome improvement activities and helps facilitate approved practice changes.
• For assigned population attends appropriate physician and Nurse leader meetings to report on trends, outcomes and statistics. Receives and acts on feedback from physicians and nursing management related to Discharge Planning.
• Participates in all appropriate and/or required hospital-wide progress, activities and efforts.

Education Required: Minimum of a Bachelor degree in Social Work or an equivalent field, Masters preferred.

Experience Required: Minimum of one year experience in a health care setting as a Social Worker or an equivalent field, 3-5 years preferred

Experience Preferred: Knowledgeable of HFAP standards, government and private insurance benefits, e.g. Medicaid, Medicare, DRGs, managed care and working knowledge of clinical review guidelines

Unexpected Perks - Daycare, Doordash, SmartDollar, Daily Pay, therapy dogs, massages, Forbes rated Best Places to Work 2022

Not quite what you are looking for? Submit your information here for general consideration. One of our employment specialists will be in touch with next steps.

EEO Statement: Reid Health is an Equal Opportunity Employer

No Search Firms:

Reid Health does not accept unsolicited assistance from search firms for employment opportunities. Please do not call or email. All resumes submitted by search firms to any employee or other representative at Reid Health via email, the internet or in any form and/or method without a vaild written search agreement in place and approved by HR will result in no fee being paid in the event the candidate is hired by Reid Health. 

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