Discharge Planner

Millennium Physician Group•New York, NY

6d•$52,877 - $79,316•Remote

About The Position

Coordinates discharge planning and care transition activities for hospitalized patients within the Millennium Physician Group Hospitalist program. The role assesses discharge needs, collaborates with physicians, nurses, case managers, patients, families, and community providers, and facilitates appropriate post-acute services to promote safe, timely transitions from the hospital. It supports continuity of care by coordinating services, educating patients and caregivers, addressing discharge barriers, and ensuring compliance with regulatory and organizational requirements. The Discharge Planner I, Hospitalists - MPG performs professional clinical work under established policies, evidence-based practices, and interdisciplinary care processes. The role uses clinical judgment to coordinate routine and moderately complex discharge plans and escalates higher-risk situations and complex psychosocial or medical issues as appropriate. Its primary impact is on individual patient outcomes, care transitions, and operational efficiency. This is a fully remote, full-time position with Monday-Friday EST hours.

Responsibilities

Assess patients' discharge planning needs using medical record review, interdisciplinary collaboration, patient interviews, and evaluation of clinical, functional, psychosocial, and environmental factors.
Develop and coordinate individualized discharge plans aligned with physician orders, patient goals, payer requirements, and available community resources.
Collaborate with hospitalists, nursing staff, case managers, therapists, pharmacists, social workers, and ancillary departments to coordinate safe and timely discharges.
Arrange appropriate post-acute services, including home health, skilled nursing facilities, rehabilitation, durable medical equipment, hospice, outpatient therapies, transportation, and community resources.
Educate patients and caregivers about discharge instructions, medications, follow-up appointments, disease management, warning signs, and community resources.
Identify discharge barriers, including authorization delays, transportation needs, caregiver limitations, equipment availability, housing concerns, and social determinants of health, and coordinate interventions.
Communicate with primary care providers, specialists, post-acute providers, payers, and external agencies to support continuity of care and reduce avoidable readmissions.
Document assessments, coordination activities, referrals, patient education, and transition plans accurately in the electronic health record and in accordance with organizational and regulatory requirements.
Monitor discharge timelines, transition metrics, and assigned caseloads in support of goals for length of stay, readmission reduction, patient satisfaction, and quality outcomes.
Participate in interdisciplinary rounds, quality improvement initiatives, patient safety activities, and care transition programs.
Maintain knowledge of applicable regulatory requirements, Medicare Conditions of Participation, payer guidelines, post-acute care resources, and evidence-based transition-of-care practices.

Benefits

3 weeks PTO and 8 paid holidays
Medical insurance
Dental insurance
Vision insurance
Employer-paid basic life coverage after one year of full-time employment
Employer-paid short-term disability coverage after one year of full-time employment
401(k) with match
Employee wellness program
Employee discount programs, including Tickets at Work and cell phone discounts
Dependent Care FSA
Voluntary life insurance
Long-term disability coverage
Critical illness coverage
Pet insurance