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Discharge Planning Specialist

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Gastonia, United States CaroMont Health Full time

Job Summary: Using independent nursing judgment, will assess, plan, facilitate, and integrate care for residents from preadmission through transitions to post discharge (Continuum of Care), including the coordination of services for patients in need of Long Term Care, Assisted Living placement, Home Health Care Services, Durable Medical Equipment, Hospice, Palliative Care, and obtaining insurance authorizations for all post facility needs when required. Participates in multidisciplinary care plans on assigned unit. Serves as resident/family advocate and liaison with medical provider. Identify preventable readmissions. Serve on various committees as assigned. Other duties as assigned.

Role includes ensuring discharge planning is in place from admission through discharge, including input and preferences for planning for discharge from resident and/or resident family or guardian. Completing any necessary documentation to facilitate timely and appropriate discharge planning (FL2s, PASARR requests). The Discharge Planning Specialist acts as a resident advocate in the multidisciplinary team. Discharge planning updates are documented ongoing as resident condition, needs, and/or preferences change in the medical record. The Discharge Planning Specialist should sign the resident’s plan of care upon initial assessment, with any change and at discharge.

Qualifications : Associate or Bachelor’s degree in nursing from a recognized college or university required; Master’s preferred. Certification in Case Management preferred. Current RN license to practice in NC (NC license or multi-state (compact) license). Two+ years clinical nursing experience. Experience in case management, long term care, quality and/or utilization management preferred. Thorough knowledge of general nursing principles, methods, techniques. Must be knowledgeable of State and Federal laws as they pertain to elderly adults and skilled nursing facilities. Exemplary verbal and written communication, critical thinking, interpersonal, group, leadership, and negotiation skills. Ability to communicate well with residents, family, staff, and medical providers to promote positive outcomes. Proficient in computer skills and MS Office software. BLS required.

EOE AA M/F/Vet/Disability