Senior Discharge Plan Manager (RN or Social Worker) UPMC Presbyterian and S

at  UPMC

Are you an RN or social worker interested in care management, case management, or care coordination? UPMC Presbyterian Shadyside is looking for a Senior Discharge Plan Manager to support their Clinical Care Coordination and Discharge Planning department!
The role of a Discharge Plan Manager will allow you to become a vital member of our team! The successful candidate will be responsible for the safe and smooth transition of our patients to their homes or other care settings. A Discharge Plan Manager works collaboratively with healthcare providers, patients, and their families to create personalized discharge plans that address the medical, social, and logistical needs of each individual.

Be an advocate for patients’ needs and preferences throughout the discharge planning process, ensuring that their voices are heard and their concerns are addressed- apply today!

• A $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!

DISCHARGE PLANNING EXPERIENCE:

• Coordination of a patient’s clinical care needs from either an inpatient hospitalization to outpatient; from a post-discharge facility to a home or assisted living facility; and/or coordination of resources to assist patients from an outpatient MD office.
• Includes, but is not limited to, insurance authorizations ( medication, transportation, alternate level of care), coordination of care to alternate levels of care ( skilled nursing homes, Inpatient rehab, home, including transportation), initiating and organizing hemodialysis, coordinating inpatient hospice, home hospice or skilled nursing with hospice; and obtaining information and connecting patients to appropriate outpatient regional resources.

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.