Discharge Planner / Social Worker

The Discharge Planner / Social Worker is responsible for overseeing and coordinating the safe and efficient discharge of residents from our facility. This position requires strong clinical skills, excellent communication abilities, and a commitment to exceptional resident care.

Schedule: Full-Time, Weekdays (M-F), 8-9 Hour Shifts

Primary Responsibilities and Duties

Supervise and coordinate the discharge planning process for residents, ensuring collaboration between the healthcare team, including physicians, therapists, social workers, and family members.

Conduct comprehensive assessments of residents’ discharge needs, including medication reconciliation, equipment requirements, and post-discharge care arrangements.

Develop individualized discharge plans in collaboration with residents, families, and caregivers, addressing preferences, goals, and clinical needs.

Provide education and instructions to residents and their families regarding patient care, medications, follow-up appointments, and other necessary information.

Communicate effectively with community resources, home health agencies, durable medical equipment providers, and other healthcare professionals to coordinate services and ensure a smooth transition for residents.

Coordinate transportation arrangements for residents’ discharge, ensuring that transportation services are arranged and available as needed.

Complete discharge paperwork accurately and ensure all required documentation is obtained, including discharge summaries, medication lists, and follow-up care instructions.

Monitor residents’ condition and progress during the discharge process, intervening as needed to address any concerns or complications.

Collaborate with the Director of Nursing and other members of the healthcare team to ensure compliance with regulatory requirements and facility policies related to discharge planning and documentation.

• Participate in team meetings to discuss discharge plans, resident progress, and any barriers to discharge.
• Perform all other duties assigned by the Director of Nursing.

Job Qualifications

1+ years of experience in a Skilled Nursing Facility is required.

Organization Skills

• Knowledge of community resources and support services available to older adults.
• Knowledge of medical terminology, charting skills, and familiarity with a skilled nursing facility.
• Strong written and verbal communication skills.
• Basic knowledge of Microsoft Office applications and operating computer hardware and software.
• Ability to build rapport with patients through a compassionate and caring demeanor.
• Demonstrated leadership and management skills, with the ability to mentor and supervise staff as needed.
• Commitment to ongoing professional development and adherence to the highest standards of nursing practice.

Physical Requirements

Work performed in a medical setting due to the need to work in person with residents and their families.

Ability to work in a variety of environments within the facility, including resident rooms, common areas, and administrative offices.

Must be able to sit, stand, bend, reach, talk, hear, stoop, kneel, crouch, stretch, twist, use hands and fingers, handle or operate objects, equipment, or controls.

Required vision includes close, vision, distance, peripheral, and the ability to adjust focus.

Emotional resilience and ability to cope with the physical and emotional demands of working with residents who may have complex healthcare needs.

Stamina to stand and move about the facility to perform frequent rounds and respond to emergent situations as needed.

Capability to lift and/or assist other nursing staff in transferring residents safely, with proper body mechanics and assistance as needed.

Maintain regular attendance and timeliness as set forth within the work schedule designated by the department supervisor/manager.

The ability to exert maximum muscle force to lift, push, pull, or carry objects.

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