Social Worker Discharge Planner​/Care Coordination Specialist

Employment Status:
Full-Time Pay Interval:
Hourly

Shift:
Days

We are seeking a highly organized, proactive, and compassionate Discharge Planner / Care Coordination Specialist to support residents and families throughout the discharge planning process in a fast-paced skilled nursing and rehabilitation setting.

This position is ideal for an individual with experience in healthcare, skilled nursing, rehabilitation, hospital case management, home health, or care coordination who excels at communication, organization, and follow-through.

Key Responsibilities:

• Coordinate safe and timely resident discharge planning from admission through discharge.
• Communicate regularly with residents, families, the interdisciplinary team, physicians, therapy, nursing, and community providers.
• Coordinate home health, durable medical equipment, transportation, follow-up appointments, and other post-discharge services.
• Identify and address potential discharge barriers early.
• Participate in interdisciplinary and discharge planning meetings.
• Maintain accurate and timely documentation and discharge tracking.
• Assist with resident and family education regarding discharge plans and next steps.
• Ensure outstanding discharge-related items are followed through to completion.
• Support a positive resident and family experience throughout the transition of care.

Preferred Qualifications:

• Experience in skilled nursing, rehabilitation, hospital discharge planning, case management, social services, home health, or healthcare coordination strongly preferred.
• Degree in Social Work, Human Services, Healthcare Administration, Psychology, Sociology, or a related field preferred; equivalent relevant healthcare experience will be considered.
• Social work licensure is not required for this position.
• Strong organizational, communication, and problem-solving skills.
• Ability to manage multiple priorities and meet time-sensitive deadlines.
• Strong computer and documentation skills.
• Must be proactive, accountable, and comfortable working collaboratively with an interdisciplinary healthcare team.

We are looking for a hands-on problem solver and strong communicator who takes ownership, anticipates barriers, and follows through until the discharge plan is complete.

• The Social Worker plans, organizes, develops, and implements Social Services programs to ensure all medically-related emotional and social needs of patients are met in accordance with all applicable laws, regulations, and Life Care standards.
• Reports to Social Services Director

• Currently registered/licensed in applicable State (if required by State law). Must maintain an active license in good standing throughout employment. (Not applicable in Hawaii)
• Bachelor’s degree in a human services field (which may include gerontology) if working in a facility with 120 or more beds (see State law)
• Two (2) years’ experience in health-care social work preferred

• Make independent decisions when circumstances warrant such action
• Knowledgeable of social services practices and procedures as well as the laws, regulations, and guidelines governing social services functions in the post-acute care facility
• Implement and interpret the programs, goals, objectives, policies, and procedures of the social services department
• Perform proficiently in all applicable competency areas
• Maintains professional working relationships with all associates, vendors, etc.
• Maintains confidentiality of all proprietary and/or confidential information
• Understand and follow company policies including harassment and compliance procedures
• Displays integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training

• Plan, organize, develop, and implement social services program that meets the medically-related social and emotional needs of patients as well as State, Federal, corporate, and division guidelines
• Act as a patient advocate and provide education to staff regarding patient rights
• Chart appropriately and timely
• Assist patients and families through education, financial planning assistance, liaison with community agencies, etc.
• Follow-up to evaluate compliance with social services programs and patient plans
• Exhibit excellent customer service and a positive attitude towards patients
• Assist in the evacuation of patients
• Demonstrate dependable, regular attendance
• Concentrate and use reasoning skills and good judgment
• Communicate and function productively within an interdisciplinary team
• Sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
• Read, write, speak, and understand the English language
• Lift 20 lbs floor to waist, lift 20 lbs waist to shoulder, lift and carry 20 lbs, and push/pull 20 lbs