Discharge Planner, Social Services Masters
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Please Note: To protect our patients, our workforce and our community, Valley Health is requiring that all newly hired employees and internal transfers (current employees requesting internal transfers) must have received at least one COVID-19 vaccination dose. Newly hired Applicants (those not currently employed by Valley Health) who have been offered a position will have to provide documentation of their vaccination status at the time of their Employee Health appointment. For internal transfers, Employee Health will contact you if they have questions around your vaccination status. Valley Health has a process for applicants who have been offered a position to request an exemption or deferral for medical or religious reasons. To search for vaccine locations, visit vaccines.gov.
- Entity: Winchester Medical Center
- Shift: Day
Who We Are
Valley Health System is a not-for-profit network of hospitals, urgent cares, physician practices, and services. Expanding across Virginia, West Virginia, and Maryland, we are devoted to the health of all who call our 18-county area home.
A vital resource for healthcare, we are the region’s largest employer, a dependable community partner, and are at the leading edge of clinical innovations.
We are looking for passionate, innovative, and caring people who will each bring their unique skills and perspectives to our workplace.
What You Will Do:
The Discharge Planner will offer clinical assessment of social, emotional, medical, spiritual and physical needs. The Discharge Planner is able to assess the patient holistically and develop a plan of care based on that assessment. This role will be actively involved with patient assessments and interviews as well as communication with family members. Contribute and/or facilitate a safe and timely discharge of patients who require post acute care services in coordination with multidisciplinary team. Contribute and/or facilitate the development of a discharge plan of care for high-risk patient populations. Crisis intervention and discharge planning to patients and families with medically/socially complex psychosocial needs. Coordinate the legal process and paperwork involved with: protective services, guardianships, adoptions, and advance directives. Assist with the arrangement and follow-up with community resources; in providing a seamless transition utilizing the entire continuum of care; and help to facilitate patients movement to the next level of care.
Duties include, but are not limited to:
Identify appropriate community resources and collaborate with patients, families, multi-disciplinary teams, and community agencies to achieve desired patient outcomes. Maintain contact with referral sources until appropriate resources are confirmed. Contribute to the development of a goal-directed, age appropriate plan of care through a multi-disciplinary team process that is prioritized and based on determined medical diagnosis, patient needs, and expected patient outcomes. Communicate with patients, families, physicians and health care staff to facilitate coordination of clinical activities and to enhance the effect of the transition from one level of care to another across the continuum. Maintain appropriate level of knowledge regarding admission, continued stay, and observation statuses for Medicare, Medicaid, and commercial insurers for all post-acute care services. Promote relationships with commercial and managed care case managers to streamline acceptance process. Review and interpret the medical record to determine the appropriateness of patient for post-acute admission to include medical history, tolerance to therapies, potential for improvement, and discharge plans. Ability to recognize, identify, and report signs and symptoms of suspected abuse and/or neglect; making and reporting appropriate referrals to CPS/APS within the specified time frame as required by VA/WV law. Provide emotional support and employ therapeutic techniques to cope with chronic, acute, or terminal illnesses. Assist medical staff with identifying decision-makers for patients who are not able to make their own medical decisions and do not have a healthcare surrogate or Medical Power of Attorney. Possess working knowledge of third party reimbursement processes as well as Medicaid processes/plans for VA and WV. Provide substance abuse assessment and resource referral information to patients identified as having potential need for substance abuse treatment. Provide information and assistance with completing advance directives and medical power of attorney forms. Attend and participate in discharge planning rounds Communicate status of plan to care team through appropriate and timely documentation. Complete Medicaid screening paperwork for VA and WV prior to patient discharge as required. Assist in the development of safety plans as needed. Coordinate and/or contribute to arranging discharges to post-acute care facilities. Assist with and coordinate adoptions. Coordinate and contribute to arranging transportation for discharge as needed. Testify in court as needed. Provide on call services as required by management at WMC. Adjust work hours and/or ensuring coverage to meet requirements of patient/family in order to optimize clinical and financial outcomes as they relate to discharge plans. Attend professional meetings, conferences, and workshops related to area of practice.
What You Will Bring:
Master’s degree from an accredited social work program or equivalent required
Previous social work experience in a medical setting desired.
Certification & Licensures
BLS Certification (Basic Life Support) - American Heart ‘Healthcare Provider’ (HCP) - AHA approved required *
* New hires must have American Heart Association (AHA) appropriate certification prior to completion of orientation.
Knowledgeable in stages of human growth and development for neonate, pediatric, adult and geriatric populations.
Skills in interpersonal relationships, clinical assessment, and group process.
High levels of verbal and written communication skills.
Ability to interact with other professionals as part of a multidisciplinary team.
Must be self-directed and have the ability to tolerate frequent interruptions and a demanding work load.
What You Will Get:
- Competitive salary
- Flexible scheduling
- Health Insurance
- Paid Time Off
- Wellness Program
- Tuition Assistance
- Retirement Plan
- Life Insurance
*some benefits are subject to change due to job status
We celebrate, support, and thrive on our differences for the benefit of our employees, our patients, and the communities we serve.
We are neighbors caring for neighbors, and our goal is always to help those we serve get well, feel well, and stay well.
Criminal Background Checks
VA State Police
3rd party Background Check
25 A Social Work