Department

SOCIAL SERVICES - 207170

Worker Sub Type

Regular

Work Shift

First Shift (United States of America)

Pay Grade

116

Job Description

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 outcomes.

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 continuum.

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 process.

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 plans.

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/WV law.

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

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 Attorney.

Possess working knowledge of third-party reimbursement processes as well as Medicaid processes/plans for VA 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 attorney forms.

Attend and participate in discharge planning rounds

Communicate status of plan to care team through appropriate and timely documentation.

Complete Medicaid screening paperwork for VA and WV prior to patient discharge as required.

Assist in the development of safety plans as needed.

Coordinate and/or contribute to arranging discharges to post-acute care facilities.

Assist with and coordinate adoptions.

Coordinate and contribute to arranging transportation for discharge as needed.

Testify in court as needed.

Provide on call services as required by 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 relate to discharge plans.

Attend professional meetings, conferences, and workshops related to area of practice.

Education

Master’s degree from an accredited social work program or equivalent required

Experience

Previous social work experience in a medical setting desired

Certification & Licensure

BLS Certification (Basic Life Support) - American Heart ‘Healthcare Provider’ (HCP) - AHA approved required. New hires must have American Heart Association (AHA) appropriate certification prior to completion of orienta