Discharge Plan Manager

Discharge Plan Manager

UPMC Altoona is seeking a full-time Discharge Plan Manager to join the Clinical Care Coordination and Discharge Planning team! This position will work Monday through Friday daylight hours, with weekend and holiday rotation.

In this model, roles are reimagined and expertise is combined to deliver the best care and personalized experiences for our patients. RNs and social workers function equally in discharge plan roles, serving as the central point of contact through a patient's care delivery, in partnership with a Physician or APP.

Become part of a multidisciplinary team committed to improving care coordination and developing more efficient, progressive discharge planning processes, and let UPMC help you succeed through offerings that include:

• A $6,000 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:

Assessment & Care Planning

• Identify clinical, psychosocial, historical, financial, cultural, and spiritual factors that shape the discharge plan.
• Consider patient/family/caregiver health literacy, understanding, and engagement when developing the plan of care.
• Evaluate the influence of social determinants of health and their impact on transition risks.
• Complete comprehensive assessments to determine self‑care capacity, support systems, barriers to discharge, and need for post‑hospital services.
• Continually reassess the discharge plan in response to changing clinical or social factors.

Care Coordination & Discharge Execution

• Lead interdisciplinary teams in developing and executing safe, efficient discharge plans.
• Maintain knowledge of local resources, service providers, and their capabilities.
• Ensure appropriate post‑hospital arrangements are made prior to discharge and avoid unnecessary delays.
• Integrate patient goals, clinical assessments, risks, and available resources to support a smooth transition.
• Serve as a liaison between the hospital, post‑hospital facilities, and involved physicians.

Communication & Collaboration

• Communicate clearly with patients, caregivers, and the interdisciplinary care team to build individualized discharge plans.
• Collaborate with attending practitioners, nurses, and other team members to coordinate care.
• Incorporate discipline‑specific recommendations, test results, and outstanding orders into the discharge plan.
• Monitor progression toward discharge milestones and adjust plans as needed.
• Promote shared accountability in developing a patient‑centered discharge plan.

Advocacy, Ethics & Compliance

• Advocate for patient safety, well‑being, rights, and access to needed services.
• Align practice with the organization's mission, vision, values, and applicable ethical standards.
• Maintain clinical knowledge and ensure compliance with all regulatory requirements.

Quality, Outcomes & Resource Stewardship

• Balance cost of care with patient safety, clinical quality, risk, and satisfaction to support optimal outcomes.
• Incorporate innovation and technology to strengthen care coordination and transitions.
• Document all planning activities and updates in the medical record.

Professional Development & Support

• Provide staff orientation, mentoring, and support as appropriate.

Discharge Planning Associate Qualifications:

• Nursing Track:
  • Diploma or associate degree in nursing and active Registered Nurse license.
  • No experience in discharge planning/care coordination. Clinical/patient-facing experience preferred.
• Social Work Track:
  • Bachelor's degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of those being served required. No license required.
  • No experience in discharge planning/care coordination. Clinical/patient-facing experience preferred.

Discharge Plan Manager Qualifications:

• Nursing Track:
  • Diploma or associate degree in nursing and active Registered Nurse license.
  • At least 1…