Job Summary: 

• Performs psychosocial assessment and screening of patients for discharge needs, including making referrals and monitoring for compliance with/adherence to the plan of care.
• Manages individuals with a focus on high-risk populations across the continuum of care.
• Refers the patient to the appropriate community resources with the patient’s understanding and cooperation.
• Acts as liaison with community and medical agencies to coordinate appropriate referrals for services.
• Coordinates and participates in family and case conferences.
• Promotes patient/family acceptance and follows through with treatment recommendations.
• Facilitates effective treatment of patient’s medical conditions and rate of recovery.
• Provides discharge planning-related in-service programs to staff as appropriate.
• Documents all patient communications and coordination in the medical record as appropriate.
• Provides post-discharge visits.

Skills on Resume:

• Psychosocial Assessment (Hard Skills)
• Care Coordination (Hard Skills)
• Referral Management (Hard Skills)
• Patient Advocacy (Soft Skills)
• Agency Communication (Soft Skills)
• Case Facilitation (Soft Skills)
• Medical Documentation (Hard Skills)
• Post-Discharge Support (Soft Skills) 

Job Summary: 

• Plan the patient discharge process, and prepare treatment plans
• Ensure patients have a smooth transition from the hospital to the community with appropriate care and services
• Plan complex discharges with a multidisciplinary team
• Take responsibility for monitoring the Patient's Length of Stay
• Develop relationships with external support services/networks (i.e. Residential facilities, TCP, and community care services)
• Complete initial needs assessment and commencement of time-critical patient care plans intending to optimize the patient's health and well-being
• Provide patients and their families with assistance and support concerning their injury or illness.
• Organize the paper, identification labels, and information patients need when leaving the hospital
• Schedule aftercare appointments for patients with PSPs, psychiatrists, next-level therapy programs, living arrangements, etc.
• Coordinate releases and fax records to providers
• Take responsibility for data entry and chart development

Skills on Resume:

• Discharge Planning (Hard Skills)
• Care Coordination (Hard Skills)
• Multidisciplinary Team Collaboration (Soft Skills)
• Length of Stay Monitoring (Hard Skills)
• External Service Relationship Development (Soft Skills)
• Needs Assessment (Hard Skills)
• Patient and Family Support (Soft Skills)
• Data Entry and Chart Development (Hard Skills)

Job Summary: 

• Maintains established departmental policies, procedures, objectives, quality improvement programs, and safety standards.
• Interviews inpatients, outpatients, and family members to obtain information about home environment, family relationships, health history, and patient’s personality traits.
• Evaluates data gathered in terms of medical plan of treatment and available social service programs, plans of pertinent therapy programs that will provide each patient with maximum benefit.
• Assist patient, family, and staff in implementing treatment plans.
• Utilizes resources to help patients resume life in the community or learn to live with the disability.
• Interprets the nature of illness and prescribed course of treatment to patients and families.
• Assists patients and families to understand, accept, and follow medical recommendations.
• Communicates family issues to other staff members.
• Participates in planning conferences.
• Assists in developing and implementing discharge plans.

Skills on Resume:

• Policy and Procedure Adherence (Hard Skills)
• Patient and Family Interviewing (Soft Skills)
• Data Evaluation (Hard Skills)
• Treatment Plan Implementation (Hard Skills)
• Resource Utilization (Hard Skills)
• Patient and Family Education (Soft Skills)
• Communication (Soft Skills)
• Discharge Planning (Hard Skills) 

Job Summary: 

• Coordinates and collaborates with other services and agencies such as Mental Health Services, Probation Officers, Primary Care Providers, Psychiatric Providers, Third Party Utilization, and any other entity that might be needed to support the success of the client once they leave treatment.
• Provides follow-up to individuals discharged from the Evaluation and Treatment facility.
• Oversees client admission and involvement in treatment.
• Completes admission intakes and contact insurance companies of admission and discharge.
• Interview clients and families to obtain information and insight regarding discharge clients’ needs and resources
• Collaborates with other community agencies with which patients and families are involved.
• Prepares and maintains required documentation on each case.
• Seeks supervisor’s consultation when barriers to plan of treatment arise.
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops.
• Attends the required number of departmental meetings per year.

Skills on Resume:

• Service Coordination (Soft Skills)
• Client Follow-Up (Soft Skills)
• Client Admission Oversight (Hard Skills)
• Insurance Coordination (Hard Skills)
• Client and Family Interviewing (Soft Skills)
• Community Agency Collaboration (Soft Skills)
• Documentation Maintenance (Hard Skills)
• Professional Development (Soft Skills)

Job Summary: 

• Collaborates with healthcare team members to develop a multidisciplinary plan of care and sets patient-centered goals for patients/families. 
• Facilitates and/or participates in discussions that provide ongoing evaluation of interdisciplinary intervention, goal attainment, and treatment plan revision.
• Knowledgeable about the patient's financial status, diagnosis, and discharge needs to develop the discharge plan of care. 
• Maintains an awareness of the patient's psychosocial situation, including the identification of potential barriers that may impact patient compliance
• Facilitates the coordination of referrals as appropriate.
• Develops collaborative relationships with other departments/entities/external healthcare agencies to facilitate and support care.
• Initiates discharge planning assessment at the time of admission and collaborates with the multi-disciplinary team for timely discharge. 
• Identifies anticipated discharge date, assesses needs, coordinates services, and financial implication of care internally and externally to meet patient needs, including medications, equipment, and home care.
• Assist with obtaining referrals and prior authorizations for Home Health Care, hospice, infusion therapy, Durable Medical Equipment (DME), Skilled Nursing Facility (SNF), acute rehab, and appointments.

Skills on Resume:

• Care Collaboration (Soft Skills)
• Goal Setting (Soft Skills)
• Discharge Planning (Hard Skills)
• Psychosocial Assessment (Hard Skills)
• Referral Coordination (Hard Skills)
• Team Collaboration (Soft Skills)
• Discharge Assessment (Hard Skills)
• Authorization Management (Hard Skills)