Discharge Planning Associate

UPMC•Jamestown, NY

About The Position

UPMC Chautauqua is hiring a Discharge Planning Associate to support its Clinical Care Coordination and Discharge Planning department. The position is full-time and day shift. Candidates may be placed in an appropriate title and salary based on their experience and education. A sign-on bonus is available. The role is part of a multidisciplinary team focused on improving care coordination and developing efficient discharge-planning processes. The associate assesses patients’ clinical and social needs, develops and coordinates safe transition plans with patients and care teams, arranges appropriate post-hospital care, and advocates for access to services and patient safety. The role also documents care in the medical chart and may provide staff orientation and mentoring. The position requires a diploma or associate degree in nursing, or a bachelor’s degree in social work or another health or human services field that promotes the well-being of those served. No license is required for the role; nurses employed in the position must maintain an active RN license.

Requirements

Diploma or associate degree in nursing, or a 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 served.
Registered nurses employed in the position must maintain an active RN license.
Excellent communication skills.
Skills in planning and organization, follow-up and control, problem solving, self-development orientation, and organizational behaviors and competencies.
Ability to apply logic and critical thinking to a wide range of problems and to deal with abstract and concrete variables.
Ability to work independently and as a team member.
Proficient computer skills.
Completion of New York Mandated Reporter training within 90 days of hire or transfer.
NYS Staff Exclusion List clearance.

Nice To Haves

Clinical or patient-facing experience preferred.

Responsibilities

Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs relevant to patient planning, while considering health literacy, understanding, engagement, preferences, and goals of care.
Assess patients’ medical and social factors, capacity for self-care, support systems, discharge barriers, likely post-hospital service needs, and service availability; reassess plans as needs or circumstances change.
Facilitate team development and execution of safe, efficient discharges, using knowledge of local resources and service-provider capabilities to arrange post-hospital care and avoid unnecessary delays.
Integrate patient goals, the care team’s assessment, risks, and available resources to develop and coordinate transition plans.
Communicate with patients, members, caregivers, and the interdisciplinary care team; serve as a liaison between patients and the care team.
Collaborate with attending practitioners, caregivers, and multidisciplinary team members to coordinate individualized care plans.
Incorporate discipline-specific recommendations, test results, and outstanding orders into discharge plans; monitor and revise plans in response to discharge milestones.
Serve as a contact between hospitals, post-hospital care facilities, and physicians providing care in those settings.
Share accountability with patients, caregivers, and team members for developing discharge plans and achieving optimal outcomes.
Align practice with the organization’s mission, vision, and values; follow applicable professional and organizational ethical standards and codes of conduct; maintain clinical knowledge and ensure compliance with regulatory requirements.
Advocate for patient and caregiver access to services and for the protection of patients’ health, well-being, safety, and rights.
Manage cost of care while considering patient safety, clinical quality, risk, and patient satisfaction when making recommendations and decisions.
Use innovation and technology to improve collaboration and patient outcomes; document care in the patient medical chart.
Provide staff orientation and mentoring as appropriate.