Discharge Planner / Social Worker

Description

The Discharge Planner /  Social Worker is responsible for overseeing and coordinating the safe and efficient discharge of residents from our facility. This position requires strong clinical skills, excellent communication abilities, and a commitment to exceptional resident care.

Schedule: Full-Time, Weekdays (M-F), 8-9 Hour Shifts

Primary Responsibilities and Duties:

• Supervise and coordinate the discharge planning process for residents, ensuring collaboration between the healthcare team, including physicians, therapists, social workers, and family members.
• Conduct comprehensive assessments of residents’ discharge needs, including medication reconciliation, equipment requirements, and post-discharge care arrangements.
• Develop individualized discharge plans in collaboration with residents, families, and caregivers, addressing preferences, goals, and clinical needs.
• Provide education and instructions to residents and their families regarding patient care, medications, follow-up appointments, and other necessary information.
• Communicate effectively with community resources, home health agencies, durable medical equipment providers, and other healthcare professionals to coordinate services and ensure a smooth transition for residents.
• Coordinate transportation arrangements for residents’ discharge, ensuring that transportation services are arranged and available as needed.
• Complete discharge paperwork accurately and ensure all required documentation is obtained, including discharge summaries, medication lists, and follow-up care instructions.
• Monitor residents’ condition and progress during the discharge process, intervening as needed to address any concerns or complications.
• Collaborate with the Director of Nursing and other members of the healthcare team to ensure compliance with regulatory requirements and facility policies related to discharge planning and documentation.
• Participate in team meetings to discuss discharge plans, resident progress, and any barriers to discharge.
• Perform all other duties assigned by the Director of Nursing.

Requirements

Job Qualifications:

• 1+ years of experience in a Skilled Nursing Facility is required.
• Organization Skills
• Knowledge of community resources and support services available to older adults.
• Knowledge of medical terminology, charting skills, and familiarity with a skilled nursing facility.
• Strong written and verbal communication skills.
• Basic knowledge of Microsoft Office applications and operating computer hardware and software.
• Ability to build rapport with patients through a compassionate and caring demeanor.
• Demonstrated leadership and management skills, with the ability to mentor and supervise staff as needed.
• Commitment to ongoing professional development and adherence to the highest standards of nursing practice.

Physical Requirements:

• Work performed in a medical setting due to the need to work in person with residents and their families.
  • Ability to work in a variety of environments within the facility, including resident rooms, common areas, and administrative offices.
• Must be able to sit, stand, bend, reach, talk, hear, stoop, kneel, crouch, stretch, twist, use hands and fingers, handle or operate objects, equipment, or controls.
• Required vision includes close, vision, distance, peripheral, and the ability to adjust focus.
• Emotional resilience and ability to cope with the physical and emotional demands of working with residents who may have complex healthcare needs.
• Stamina to stand and move about the facility to perform frequent rounds and respond to emergent situations as needed.
• Capability to lift and/or assist other nursing staff in transferring residents safely, with proper body mechanics and assistance as needed.
• Maintain regular attendance and timeliness as set forth within the work schedule designated by the department supervisor/manager.
• The ability to exert maximum muscle force to lift, push, pull, or carry objects.

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