GENERAL DESCRIPTION
The Discharge Planner (DCP) assesses patients at admission and coordinates a safe, timely discharge plan. Working with the patient, family, and care team, the DCP ensures medical and psychosocial needs are identified and supported for a smooth transition of care.
Job Duties:
ESSENTIAL DUTIES AND RESPONSIBILITIES
• Assesses the patient’s needs and develops an appropriate discharge plan for post‑hospital care.
• Evaluates the patient’s ability and available resources to support care at home.
• Collaborates with the patient, family, and interdisciplinary care team to create a realistic discharge plan that addresses medical and psychosocial needs.
• Coordinates and manages all aspects of the discharge process to ensure a smooth transition to home or another care facility.
• Monitors patient progress and adjusts the discharge plan as needed.
• Facilitates referrals to external healthcare facilities, community agencies, or support services.
• Advocates for the patient’s needs, preferences, and goals throughout the discharge process.
• Arranges follow‑up appointments, placement in another care facility, home health or hospice services, and any required medical equipment.
• Educates patients and families on Medicare, Medicaid, and third‑party insurance coverage related to discharge planning.
• Maintains up‑to‑date knowledge of regulatory requirements, including Medicare, Medicaid, and other payer guidelines.
• Refers patients to the Patient Benefit Coordinator (PBC) for assistance when appropriate.
• Maintains accurate, timely documentation of all discharge planning activities and communicates relevant information to the care team.
• Other duties as assigned.
LEVEL OF RESPONSIBILITY
• Performs work under general supervision.
• Handles moderately complex issues and problems, and refers more complex issues to higher-level staff.
• Possesses solid working knowledge of subject matter.
QUALIFICATIONS
• Bachelor's degree in Social Work, Nursing, or a related health field; no substitutions.
• At least two (2) years of experience in a related role.
COMPETENCIES
• Teamwork and Collaboration.
• Oral and written communication skills.
• Problem-solving skills.
• Organization and Time Management.
• Interpersonal skills.
• Attention to Detail.
PHYSICAL REQUIREMENTS
• While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk; sit and use hands to finger, handle, or feel. The employee is occasionally required to reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl and taste or smell. The employee must occasionally lift and/or move up to 25 pounds.
CERTIFICATES, LICENSES, REGISTRATIONS
• Must possess a valid driver's license with a driving history verified through a motor vehicle report that meets requirements for Cherokee Nation underwriting rating.
• Must possess and maintain Basic Life Support (BLS) certification, or obtain it within one (1) year of hire and maintain it throughout employment.
• Licensure as a Licensed Master’s Social Worker (LMSW), Licensed Social Worker Associate (LSWA), or Registered Nurse (RN) is preferred but not required; any licensure held must be maintained throughout employment.
OTHER REQUIREMENTS
• The employee must not be and will not be under sanction by the United States Department of Health and Human Services Office of the Inspector General (OIG) or by the General Services Administration (GSA) or listed on the OIG's Cumulative Sanction Report, or the GSA's List of Excluded Providers, or listed on the OIG's List of Excluded Individuals/Entities (LEIE).
• Must meet and maintain pre-employment and periodic background investigation and adjudication for childcare.