POSITION SUMMARY

The discharge planner is responsible for developing, coordinating, and executing individualized discharge and aftercare plans for patients across all levels of care, beginning at admission and continuing through the patient's transition out of the program. The

DISCHARGE PLANNER

works in partnership with the clinical team, medical staff, utilization review, and outside providers to ensure that each patient leaves treatment with an appropriate next level of care, scheduled follow-up services, and the supports necessary to sustain recovery. The

DISCHARGE PLANNER

is responsible for recording and monitoring communications, referrals, and coordination activities related to discharge, and for ensuring that discharge documentation is accurate, timely, and complete in accordance with facility policies and procedures and the standards of State and Federal Regulations, accreditation bodies, and payer requirements. The

DISCHARGE PLANNER

may also carry an assigned caseload or provide other clinical coverage as directed by the clinical supervisor, including individual sessions, group facilitation, activities, and assessments.

ESSENTIAL DUTIES AND RESPONSIBILITIES

The essential functions include, but are not limited to the following: Discharge and Aftercare Planning

• Initiate discharge planning at admission and update the plan throughout the patient's course of treatment; discharge planning is a continuous process, not an end-of-stay task.
• Complete discharge planning assessments identifying the patient's aftercare needs, including clinical, medical, housing, financial, legal, vocational/educational, transportation and recovery support needs.
• Develop an individualized, written discharge plan with the patient that reflects the patient's stated goals, identified barriers, and recovery capital.
• Identify and address barriers to discharge early, escalating unresolved barriers to the treatment team and/or clinical supervisor.
• Schedule aftercare appointments prior to discharge, including behavioral health, medical, prescriber, and support services, targeting a first appointment within 7 days of discharge.
• Coordinate continuity of medication-assisted treatment, including prescriber appointments, bridge prescriptions and pharmacy arrangements, in collaboration with medical and nursing staff.
• Arrange housing placement as indicated, including recovery housing, sober living, transitional or emergency housing, and verify the placement prior to discharge.
• Arrange transportation to the next level of care or discharge destination.
• Ensure each patient is discharged with written discharge instructions, a crisis and relapse prevention plan, and contact information for aftercare providers and crisis services. Level of Care Transitions
• Coordinate step-down transitions between internal levels of care — detoxification, residential, partial hospitalization and intensive outpatient — ensuring continuity of care and minimal lapse in service.
• Work with utilization review and the clinical team regarding continued stay, anticipated discharge dates, and authorization for the next level of care.
• Complete referrals and transfer documentation for patients transitioning to external providers or higher levels of care, including verification that the receiving provider has accepted the patient.
• Conduct warm handoffs to receiving providers wherever possible, rather than referral by paperwork alone. Coordination and Communication
• Participate in departmental and cross-departmental communication and treatment team meetings; present discharge status, projected discharge dates, and outstanding barriers for assigned patients.
• Complete phone calls with patients and all communication with outside providers, including releases of information required to coordinate care.
• Facilitate a bridge between the patient and community resources to resolve identified needs
• Develop and maintain current working knowledge of the community provider network, including availability, admission criteria, insurance acceptance and referral processes. Documentation
• Complete documentation of discharge planning activity, including individual sessions, referrals made, provider contacts, and patient response to the plan.
• Ensure discharge planning and instructions are completed throughout the patient's treatment and are clear, complete and individualized, in collaboration with the clinical team.
• Complete discharge summaries and closing documentation within 2 days of discharge and in accordance with facility, accreditation and payer requirements.
• Document and process discharges, transfers and AMAs (Leaving Against Medical Advice), including the AMA protocol, risk mitigation offered, and the disposition provided to the patient.
• Complete post-discharge follow-up contact where required, and document the outcome including whether the patient attended aftercare.
• Track and report discharge outcome data, including aftercare connection rates, AMA rates, and readmissions, as assigned.

Clinical Coverage and Assigned Caseload The

DISCHARGE PLANNER

may be assigned a caseload or provide clinical coverage as program needs require. When assigned, duties include:

• Case Management Initial Assessment(s), Orientation to programming, Intake Screening and Assessments.
• Individual session(s) and progress notes.
• Documentation and facilitating of group as assigned

WORKING CONDITIONS AND 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. The noise level in the work environment is usually moderate. Position is required to work in indoor and outdoor environments as needed. Position requires travel between facility locations and may require travel into the community to coordinate placements and accompany patients to appointments. Potential exposure to violent situations. Potential exposure to airborne/bloodborne pathogens and other potentially infectious materials.

QUALIFICATIONS & EDUCATION

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Preferred at least 1 year of working with people with behavioral health needs (trauma, mental illness and/or substance abuse)
• Preferred experience in discharge planning, care coordination, or case management services in the mental health or Substance Abuse community
• Experience working on a multidisciplinary team
• Working knowledge of levels of care across the behavioral health continuum and of ASAM criteria
• Tenacity and ability to think out of the box and work creatively to engage participants
• Knowledge of the criminal justice system and community resources
• Computer literate. Proficient in Microsoft Office and Google applications
• Excellent verbal and written communication skills
• Valid driver's license and ability to meet facility driving requirements preferred
• CDCA required; Associate's Degree or higher preferred

SKILLS AND ABILITIES

• Ability to work as a team member and have management, communication, organizational and interpersonal skills
• Ability to manage multiple concurrent discharges with competing timelines and to prioritize under time pressure
• Ability to work under stressful conditions and be flexible in relation to department needs
• Knowledge of Joint Commission standards within the Department
• Demonstrates Proficiency in Verbal and written Communication Skills
• Knowledge of State and Federal Statutes Regarding Patient Confidentiality Laws, including 42 CFR Part 2
• Familiar with community resources, recovery housing, recovery supports and mutual aid resources

PHYSICAL DEMANDS

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. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk and sit. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl.

Pay:

$43,680.00 - $49,920.00 per year

Benefits:

Dental insurance Health insurance Life insurance Vision insurance People with a criminal record are encouraged to apply

Experience:

Substance Abuse Disorders:

1 year (Preferred)

License/Certification:

CCDA (Preferred)

Work Location:

In person