Expert Discharge Plan Manager (RN or Social Worker) UPMC Presbyterian

Are you an RN or social worker interested in care management, case management, or care coordination? UPMC Presbyterian is looking for an Expert Discharge Plan Manager to support their Clinical Care Coordination and Discharge Planning department!

The role of a Expert 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!

This RN or Social Work Discharge Planning position is in the Presbyterian Emergency Department and has rotating shifts that can include daylight/evening/overnight coverage with 12-hour shifts and a flexible schedule. The Presbyterian Emergency Department Discharge Planning team are responsible for 24/7 coverage.

• 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!

Responsibilities

• Performs in accordance with system-wide competencies/behaviors.
• Performs other duties as assigned.
• Advocate on behalf of patient/family/caregivers for services access and for the protection of the patient's health, well-being, safety, and rights.
• Align practice with the mission, vision, and values of the organization.
• Adheres to ethical standards and codes of conduct of the applicable professional organizations and UPMC.
• Maintain clinical knowledge of and ensures compliance with regulatory requirements.
• Assist in operational activities for the department including staff orientation, mentoring, and other issues.
• Complete detailed assessment of every patient in order to establish an understanding of medical and social factors, determine patient's capacity for self-care, identify support systems, outline barriers to discharge, and determine the likeliness of requiring post-hospital services and the availability of such services.
• Continually reassess the discharge plan for factors that may affect continuing care needs or the appropriateness of the discharge plan.
• Demonstrate skilled expertise in discharge planning functions.
• Embrace and incorporate innovation and technology to improve collaboration and patient outcomes.
• Document care inpatient medical chart.
• 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, and outstanding orders into the discharge plan and monitor/revise and respond to the progression of discharge milestones.
• 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.
• 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.
• Lead process improvement initiatives.
• Manage the cost of care with the benefits of patient safety, clinical quality, risk, and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes.
• Recognize and demonstrate shared accountability in the development of a discharge plan with the patient/member/caregiver as well as with team members to ensure optimal outcomes.
• 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.

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.

Nurse Track

• Nurse track: BSN required.

Non-Nurse Track

• MSW or master's degree in another health and human services field that promotes the physical, psychosocial, and/or vocational well-being of those being served is required.

Licensure, Certifications, and Clearances:

Nurse Track

• RN License Required.
• CCM/ACM or other nursing or social work certification is required.

Non-Nurse Track

• LSW, LCSW or education-appropriate license required.
• CCM/ACM or other nursing or social work certification required.

Other

• Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR)
• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran

Individuals hired into this role must comply with UPMC’s COVID vaccination requirements upon beginning employment with UPMC. Refer to the COVID-19 Vaccination Information section at the top of this page to learn more.