The Discharge Planner provides a broad range of support services to the Care Coordinators and to the licensed Clinical Social Workers with their transition planning activities. These activities include referrals to post-acute agencies, scheduling discharge appointment for primary care specialists or clinics, and clerical activities as needed. The Discharge Planner is also responsible to document all discharge planning activities appropriately in the medical record. Work is performed under the direct supervision of a Social Work manager.

Primary Duties and Responsibilities

Assists in locating facilities appropriate for patient’s needs: contacts skilled nursing facilities, Long Term Acute care and Acute Rehab Facilities to determine bed availability and communicates with the case management team.

Assists patients with Durable Medical Equipment (DME) as needed to meet the home care needs of the patient as ordered by the physician and meeting payer requirements.

Contact insurance companies/ medical groups to acquire authorization for post-acute services when applicable.

Meets with patients and families to offer transportation options and coordinates the trip.

Assists and advocates for patients to obtain housing, food, insurance, public entitlements, legal representation and other community resources or linkages as applicable to the individual’s needs. 

Makes post discharge appointment in collaboration with the patient/family: performs follow-up on post discharge matters as required

Evaluates patient needs/requests; reports observation and brings urgent and/or crisis situations to the attention of the team immediately.

Consults and cooperates with other professionals and agency personnel to aid them in recognizing the significant social components of health care and understanding their impact on patients and their families. 

Demonstrates a culturally sensitive approach to patient and families.