Discharge Plan Manager, UPMC

UPMC East is searching for a full-time Discharge Plan Manager! Are you an RN or social worker interested in care management, case management, or care coordination? UPMC is proud to announce the Clinical Care Coordination and Discharge Planning team, dedicated to caring for patients throughout their UPMC treatment journey. This full-time role will work primarily Monday-Friday 7:30am-4pm shifts but would occasionally rotate through weekend and holiday coverage (approximately 1 weekend every 8 weeks). You'll assist in covering our UPMC East inpatient 6 West Acute Care Unit as well as some time in our PACU . Our Discharge Plan Managers work with many different staff members in patient care and this is a great team with diverse backgrounds. If you're ready to join our life changing medicine group, we invite you to apply today! In this new model, roles are reimagined, and expertise is combined to deliver the best care and personalized experiences for our patients. RNs and social workers function equally in discharge plan roles, serving as the central point of contact through a patient's care delivery, in partnership with a Physician or APP. Your Discharge Plan job title and pay will be determined by your previous experience and education. Salary shown is for our Senior Discharge Plan Manager title. Up to $10,000 sign-on bonus for eligible roles with a two-year work commitment Become part of a multidisciplinary team committed to improving care coordination and developing more efficient, progressive discharge planning processes, and let UPMC help you succeed through offerings that include:

• A designated career ladder designed to support career advancement, with two tracks to support both nurses and social workers
• Flexible schedule options to make your career work for you
• Up to 5 ½ weeks of paid time off and 7 paid holidays
• $6,000/year in tuition assistance to help you get where you want to be
• And much more!

Responsibilities:

• Work with patients throughout their treatment journey — from day one of admission to post-discharge — to ensure patients are prepared for a successful discharge and achieve continued improvement following inpatient care.
• Advocate on behalf of patient/family/caregivers for access to services and for protecting the patient's health, well-being, safety, and rights.
• Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes.
• Complete detailed patient assessments to determine patients' capacity for self-care, identify support systems, outline barriers to discharge, and determine the likelihood that patients will require post-hospital services and the availability of those services.
• Collaborate with a multidisciplinary team to coordinate an individualized, safe, efficient care plan. Integrate patients' goals, the health care team's assessment, risks, and available resources to develop and coordinate a successful transition plan.
• Serve as a liaison between patients and the care team. Incorporate discipline-specific recommendations, test results, and outstanding orders into the discharge plan and respond to the progression of discharge milestones.
• Maintain knowledge of resources in the area, their capabilities and capacities, and service providers available. Ensure appropriate arrangements for post-hospital care will be made before discharge and work to avoid unnecessary delays in discharge.
• Serve as a contact between hospitals and post-hospital care facilities and the physicians who provide care in both settings.

Responsibilities:

Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes. Take patient/family/caregiver level of health literacy into consideration. Evaluate patient/family/caregiver level of understanding and engagement with the progress toward goals and incorporate findings into the plan of care. Balances resources with patient preferences and goals of care. Evaluate the potential impact of social determinants of health that may elevate the risk of a poor transition. Complete detailed assessment on every patient in order to establish understanding of medical and social factors, determine patient's capacity for self-care, identify support systems, outline barriers to discharge, and determine likeliness of requiring post-hospital services and the availability of such services. Continually reassess discharge plan for factors that may affect continuing care needs or the appropriateness of the discharge plan. Facilitate teams to develop and execute safe and efficient discharges. Maintain knowledge about area resources and their capabilities and capacities as well as various types of service providers available. Ensure appropriate arrangements for post-hospital care will be made before discharge and work to avoid unnecessary delays in discharge. Integrate patients' goals, the health care team's assessment, risks and available resources in order to develop and coordinate a successful transition plan. Engage in clear communication with the patient/member/caregivers as well as the interdisciplinary care team in order to develop discharge plans. Serve as a liaison between the patient and the care team. Actively collaborate with the attending practitioner, caregivers, and other members of the multidisciplinary team to coordinate an individualized plan of care. Incorporate discipline-specific recommendations, test results, outstanding orders into discharge plan and monitor/revise and respond to the progression of discharge milestone. Serve as a contact between hospitals and post-hospital care facilities as well as the physicians who provide care in either or both of these settings. Recognize and demonstrate shared accountability in development of a discharge plan with the patient/member/caregiver as well as with team members to ensure optimal outcomes. Align practice with the mission, vision, and values of the organization. Adheres to ethical standards and codes of conduct of applicable professional organization and UPMC. Maintain clinical knowledge of and ensures compliance with regulatory requirements. Advocate on behalf of patient/family/caregivers for services access and for the protection of the patient's health, well-being, safety, and rights. Manage cost of care with the benefits of patient safety, clinical quality, risk and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes. Embrace and incorporate innovation and technology to improve collaboration and patient outcomes. Document care in patient medical chart. Assist in operational activities for the department including staff orientation, mentoring, and other issues. Demonstrate expertise in relevant content area. Participate in process improvement initiatives.