Discharge Planner II, Social Services

Valley Health System•Winchester, VA

11d

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 supports safe, timely discharges for medically and socially complex patients through psychosocial support, resource navigation, and coordination with interdisciplinary teams. The position also supports end-of-life care and Medical Power of Attorney decision-making, and intervenes in matters involving abuse, neglect, or guardianship.

Requirements

Bachelor’s degree from an accredited social work program or equivalent.
Two years of previous social work experience in a medical setting.
Current BLS Certification (Basic Life Support) from an American Heart Association-approved provider; 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 collaborate effectively within a multidisciplinary team and interact well with internal and external customers at all levels.
Critical-thinking and creative problem-solving abilities.
Ability to be innovative and flexible in response to changing needs and priorities.
Strong organizational and planning skills.
Ability to work independently, manage multiple priorities, tolerate frequent interruptions, and handle a demanding workload.
Self-directed approach and 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, documenting plans 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 plan safe and effective discharges.
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, including needs related to chronic, acute, or terminal illness.
Assess substance abuse, advance directives, and medical decision-making needs; assist with completing 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 and transitions across the continuum of care are seamless.
Coordinate legal processes related to guardianships, adoptions, advance directives, and protective services.
Make timely CPS/APS referrals 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 effectively 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.