Job Description

NOW HIRING! ~ Patient Discharge Planner.

Position Summary

Pointe Meadows Health and Rehabilitation is a Medicare 5-star facility that is seeking a compassionate and detail-oriented Discharge Planner / Case Manager to join our Skilled Nursing Facility team. This role is responsible for coordinating patient discharges, ensuring continuity of care, and collaborating with interdisciplinary teams to achieve safe, timely, and effective transitions.

The ideal candidate is highly organized, patient-focused, and experienced in post-acute care planning, insurance coordination, and communication with patients, families, and providers.

Key Responsibilities

• Coordinate and facilitate patient discharge planning from admission through discharge
• Collaborate with physicians, nursing staff, therapy teams, and families to develop appropriate discharge plans
• Arrange post-discharge services including home health, DME, outpatient services, and community resources
• Be part of the facility leadership team with investment in the results of the entire building
• Ensure compliance with Medicare, Medicaid, and insurance guidelines
• Communicate effectively with patients and families regarding discharge options and care plans
• Maintain accurate and timely documentation in accordance with regulatory requirements
• Participate in interdisciplinary team meetings and care plan discussions
• Identify and address barriers to discharge and work to resolve issues proactively

Qualifications

• Experience in discharge planning, case management, or social services in a skilled nursing or healthcare setting preferred
• Strong knowledge of post-acute care services, insurance processes, and care coordination
• Excellent communication, organizational, and problem-solving skills
• Ability to manage multiple cases in a fast-paced environment

*Our expectation : is that you will perform your job in a manner consistent with our Core Values CELEBRATION – ACCOUNTABILITY - PASSION FOR LEARNING - LOVE ONE ANOTHER - INTELLIGENT RISK TAKING - CUSTOMER SECOND - OWNERSHIP

*The Many Perks We Offer!! -

*Bonus Programs!

*Quick Career Advancement Opportunities!

*Career Path Development

*Employee referral program

*Tuition Reimbursement Program

*Cell Phone, Movie Ticket, and other major Discounts

*Medical, Dental, Life Insurance

*Mentorship and Training

*401(k) with Matching Contributions

+Plus, more! Ask us out about all of the amazing perks we offer.

Responsibilities:

• Collaborate with the interdisciplinary team to develop individualized discharge plans for patients based on their medical condition, needs, and preferences.
• Coordinate with external agencies, healthcare providers, and community resources to arrange post-discharge services such as home health care, rehabilitation, durable medical equipment, and transportation.
• Conduct comprehensive assessments of patients' physical, emotional, and social needs to identify potential barriers to a safe and successful discharge.
• Educate patients and their families about available community resources, support programs, and self-care techniques to promote independence and enhance overall well-being.
• Provide counseling and emotional support to patients and families during the discharge planning process.
• Monitor and evaluate the effectiveness of discharge plans, making adjustments as necessary to ensure optimal outcomes.
• Maintain accurate and up-to-date documentation of discharge plans, assessments, and coordination activities in accordance with regulatory standards and facility policies.
• Collaborate with other healthcare professionals, including physicians, nurses, social workers, and therapists, to ensure coordinated and integrated care.

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION/EXPERIENCE:

• *Preferred: bachelor’s degree in social work, Nursing, or Therapy or a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology. (Not Required)
• *Preferred, as a minimum, 3-5 years of work experience, preferably in a hospital, long-term care facility, or other related health care facility. (Not Required)

Other Specific Requirements:

• Must provide evidence of being free of tuberculosis infection upon hire and as set forth by the policies of the facility.
• Must be able to read, write, speak and understand the English language. (Basic English)
• Must possess the ability to make independent decision when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
• Must be knowledgeable of and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
• Attend and participate in workshops, seminars, etc., to keep abreast of current changes in the long-term care field, as well as to maintain a professional status.
• Create and maintain an atmosphere of warmth, personal interest, and positive emphasis, as well as a calm environment throughout the facility.
• Must have patience, tact, cheerful disposition and enthusiasm, as well as be willing to handle residents based on whatever maturity level in which they are currently functioning or other difficult situations.

At Pointe Meadows (Skilled Nursing Facility) we put our employees first! We make it a priority to celebrate our accomplishments and acknowledge our success is driven by our employees. We want employees who want to be a part of a top-notch team and who want to make a positive difference in the lives of the elderly and vulnerable population. We encourage growth and want to help employees meet their personal and professional goals. Because of this, we provide ongoing training, mentoring, tuition reimbursement programs and scholarships to employees. As a team we are driven to provide exceptional service by cultivating a workforce that is dedicated in delivering care with compassion and integrity.

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