Discharge Plan Manager

at  UPMC Pittsburgh Medical Center

UPMC East is searching for a full-time Discharge Plan Manager!
Are you an RN or social worker interested in care management, case management, or care coordination? UPMC is proud to announce the Clinical Care Coordination and Discharge Planning team, dedicated to caring for patients throughout their UPMC treatment journey. This role will work primarily Monday-Friday 7:30am-4pm shifts but would occasionally rotate through weekend and holiday coverage (approximately 1 weekend every 8 weeks). Our Discharge Plan Managers assist in covering our inpatient units and work with many different staff members in patient care. This is a great team with diverse backgrounds. If you’re ready to join our life changing medicine group, we invite you to apply today!
In this new model, roles are reimagined, and expertise is combined to deliver the best care and personalized experiences for our patients. RNs and social workers function equally in discharge plan roles, serving as the central point of contact through a patient’s care delivery, in partnership with a Physician or APP. Your Discharge Plan job title and pay will be determined by your previous experience and education. Salary shown is for our Discharge Plan Manager title.

Become part of a multidisciplinary team committed to improving care coordination and developing more efficient, progressive discharge planning processes, and let UPMC help you succeed through offerings that include:

• Up to $10,000 sign-on bonus for eligible roles with a two-year work commitment
• A designated career ladder designed to support career advancement, with two tracks to support both nurses and social workers
• Flexible schedule options to make your career work for you
• Up to 5 ½ weeks of paid time off and 7 paid holidays
• $6,000/year in tuition assistance to help you get where you want to be
• And much more!

Responsibilities:

• Work with patients throughout their treatment journey — from day one of admission to post-discharge — to ensure patients are prepared for a successful discharge and achieve continued improvement following inpatient care.
• Advocate on behalf of patient/family/caregivers for access to services and for protecting the patient’s health, well-being, safety, and rights.
• Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes.
• Complete detailed patient assessments to determine patients’ capacity for self-care, identify support systems, outline barriers to discharge, and determine the likelihood that patients will require post-hospital services and the availability of those services.
• Collaborate with a multidisciplinary team to coordinate an individualized, safe, efficient care plan. Integrate patients’ goals, the health care team’s assessment, risks, and available resources to develop and coordinate a successful transition plan.
• Serve as a liaison between patients and the care team. Incorporate discipline-specific recommendations, test results, and outstanding orders into the discharge plan and respond to the progression of discharge milestones.
• Maintain knowledge of resources in the area, their capabilities and capacities, and service providers available. Ensure appropriate arrangements for post-hospital care will be made before discharge and work to avoid unnecessary delays in discharge.
• Serve as a contact between hospitals and post-hospital care facilities and the physicians who provide care in both settings.

Qualifications - Internal

• At least one year of experience in discharge planning/care coordination is required. This may include but is not limited to: coordination of a patient’s clinical care needs in various settings such as inpatient, outpatient, post-discharge facilities, home or assisted/skilled living facilities, rehab, hospice; conducting insurance authorizations (medication, transportation, alternate level of care), obtaining information and connecting patients to appropriate outpatient regional resources, etc.

• RN Qualifications: Diploma or associate’s degree required

• • Social Worker Qualifications: Bachelor’s degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of those being served is required; a Master’s degree preferred.

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.
• 1) Diploma or associate degree in nursing and active Registered Nurse license and at least one year of experience in discharge planning/care coordination required OR 2) Bachelor’s degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of those being served required. Master’s degree preferred and at least one year of experience in discharge planning/care coordination required.
• KNOWLEDGE AND SKILLS: Must possess knowledge in navigating communications with payer sources and programs. Possess knowledge and understanding of regulatory guidelines. Must be skilled in planning/organization, follow up/control, delegation. Problem solving, self-development, organizational behaviors/competencies. Must be able to read, understand, analyze, and interpret medical record documents. Must possess the ability to apply principles of logic and critical thinking to a wide range of problems and to deal with a variety of abstract and concrete variables. Demonstrate ability to function independently, taking initiative to be proactive and drive a discharge plan while working with a multi-disciplinary team. Be able to lead care teams to develop and execute safe and efficient discharge plans. Maintain knowledge about area resources and their capabilities and capacities as well as various types of service providers available. Demonstrate understanding of inpatient care setting operations. Ability to manage multiple priorities in a fast-paced environment.LICENSURE, CERTIFICATIONS, AND CLEARANCES:Registered Nurses employed in this position are required to maintain active RN license. OR Those without an active RN license, an LBSW or other related healthcare professional license required. CCM or ACM or other nursing or social work certification preferred.
• Licensed Bachelors Social Work (LBSW) OR Licensed Clinical Social Worker (LCSW) OR Licensed Social Worker (LSW) OR Other Healthcare Professional Licenses for Discharge Planning OR Registered Nurse (RN)
• Act 34
• Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

Responsibilities:

• Work with patients throughout their treatment journey — from day one of admission to post-discharge — to ensure patients are prepared for a successful discharge and achieve continued improvement following inpatient care.
• Advocate on behalf of patient/family/caregivers for access to services and for protecting the patient’s health, well-being, safety, and rights.
• Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes.
• Complete detailed patient assessments to determine patients’ capacity for self-care, identify support systems, outline barriers to discharge, and determine the likelihood that patients will require post-hospital services and the availability of those services.
• Collaborate with a multidisciplinary team to coordinate an individualized, safe, efficient care plan. Integrate patients’ goals, the health care team’s assessment, risks, and available resources to develop and coordinate a successful transition plan.
• Serve as a liaison between patients and the care team. Incorporate discipline-specific recommendations, test results, and outstanding orders into the discharge plan and respond to the progression of discharge milestones.
• Maintain knowledge of resources in the area, their capabilities and capacities, and service providers available. Ensure appropriate arrangements for post-hospital care will be made before discharge and work to avoid unnecessary delays in discharge.
• Serve as a contact between hospitals and post-hospital care facilities and the physicians who provide care in both settings