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MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in Social Work, Psychology, Sociology, Nursing, or related field.

2. State criminal background check and Federal (if applicable), as required for regulated areas.

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. One (1) year experience in a healthcare setting.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Participates as an integral professional member of an interdisciplinary team.

2. Collects and records data that is comprehensive, accurate, and systematic in the assessment form and in progress notes.

3. Assesses and documents in the medical record the discharge planning needs of the patient.

4. Contacts the referral source(s) and appropriate health professionals involved in the patient’s discharge status and to obtain any additional information that might facilitate the treatment process.

5. Advocates on behalf of the patient to maximize available services.

6. Assists treatment team by coordinating planning effort. Assists in determining appropriateness of admissions and receives referrals for discharge planning intervention.

7. Establishes and maintains a collaborative environment in coordination with the patient and other healthcare providers.

8. Assists patients and families in achieving a satisfying and productive discharge plan through health teaching and documents teaching according to hospital policy.

9. Performs discharge planning as developed with the treatment team from day of admission. Acts as liaison for patients and their families to various community agencies, hospital consultants and services.

10. Participates in improving organizational performance and other means of evaluation to assure quality of nursing and discharge planning services provided for patients.

11. Attends continuing education seminars and in-services as necessary to maintain professional licensure, competency, and to satisfy hospital-required educational standards.

12. Coordinates post-acute care planning including referrals to skilled nursing, rehabilitation, home health, or durable medical equipment providers.

13. Provides education to patients and families to support discharge readiness and ensure understanding of post-discharge instructions and available services.

14. Demonstrates working knowledge of Medicare, Medicaid, and private insurance guidelines relevant to post-acute services and transitions of care.

15. Provides timely documentation of discharge planning activities, patient/family communications, and care coordination in accordance with hospital policy and regulatory standards.

16. Collaborates with case managers, utilization review, and third-party payors to support timely transitions and resolve coverage or authorization issues.

17. Assists patients and families in navigating community-based resources, including transportation, housing, or medical support programs.

18. Participates in weekend or holiday rotations as needed to ensure continuity of discharge planning services if applicable for your assigned unit.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Frequent walking, standing, stooping, kneeling, reaching, pushing, pulling, lifting, grasping are necessary body movements utilized in performing duties through the work shift.

2. When working on inpatient units must be able and willing to participate in physical restraint of patient if needed.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Healthcare setting.

SKILLS & ABILITIES:

1. Must have independent decision-making ability.

2. Ability to work with multi-disciplinary groups and facilitate meetings.

3. Ability to work independently or cooperatively as a team member.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center:

Address:

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.