Discharge Planner II, Social Services

Valley Health•Winchester, VA

13d•$26 - $40

About The Position

The Discharge Planner II provides holistic patient assessments and develops individualized care plans addressing social, emotional, medical, spiritual, and physical needs. The role helps ensure safe, timely discharges for medically and socially complex patients while providing psychosocial support and helping patients navigate resources. It includes coordinating care with interdisciplinary teams, organizing treatment plans, identifying discharge needs, educating patients and families about community resources, and intervening in matters involving abuse, neglect, or guardianship. The position also supports decision-making related to end-of-life care and Medical Power of Attorney.

Requirements

Bachelor’s degree from an accredited social work program or equivalent.
Two years of social work experience in a medical setting.
BLS Certification (Basic Life Support) from an American Heart Association-approved Healthcare Provider course; new hires must obtain appropriate AHA certification before completing orientation.
Ability to recognize, identify, and report signs and symptoms of suspected abuse or neglect.
Knowledge of abuse and neglect indicators and reporting requirements.
Knowledge of human growth and development across neonate, pediatric, adult, and geriatric populations.
Familiarity with third-party reimbursement, Medicaid processes and plans for Virginia and West Virginia, and discharge planning processes.
Knowledge of funding, resources, services, clinical standards, and outcomes.
Strong verbal and written communication skills.
Ability to interact and collaborate effectively within a multidisciplinary team.
Excellent interpersonal skills with internal and external customers at all levels.
Demonstrated critical-thinking and creative problem-solving abilities.
Ability to be innovative and flexible in responding to changing needs and priorities.
Proficient organizational and planning skills.
Ability to work independently, manage multiple priorities, tolerate frequent interruptions, and handle a demanding workload.
Self-directed with strong time-management capabilities.
Experience with computer technology, including Windows-based programs, email, and Microsoft Word.

Nice To Haves

Master’s degree from an accredited social work program or equivalent.

Responsibilities

Coordinate patient care with clinical partners to achieve realistic and desirable outcomes.
Develop, implement, and communicate discharge plans for medically complex cases, and document them in the medical record.
Facilitate interdisciplinary care planning meetings and delegate tasks to support team members.
Use post-acute care facilities and collaborate with financial partners to support safe and effective discharge planning.
Conduct psychosocial assessments to identify long-term care needs and barriers to discharge.
Provide crisis intervention and emotional support to patients and families with complex psychosocial needs.
Support patients and families with emotional needs related to chronic, acute, or terminal illness.
Assess substance abuse, advance directives, and medical decision-making needs; assist with completion of related forms.
Educate patients and families about community resources and assist with referrals to support continuity of care.
Maintain contact with referral sources until resources are confirmed, supporting seamless transitions across the continuum of care.
Coordinate legal processes related to guardianships, adoptions, advance directives, and protective services.
Make timely referrals to CPS/APS as required by state law and testify in court when necessary.
Ensure compliance with Medicare, Medicaid, and commercial insurance requirements for post-acute care.
Complete Medicaid screening paperwork and maintain accurate, timely documentation of plans and status updates.
Communicate with patients, families, physicians, and care teams to support transitions of care.
Partner with leadership to address discharge delays, barriers, and emerging trends.
Perform other duties as assigned.