Discharge Planner

Job Title: Discharge Planner
Location: Aviara Healthcare, Encinitas CA
Schedule: Full-Time

Position Summary:

The Discharge Planner is responsible for coordinating and facilitating safe, timely, and appropriate discharges for residents transitioning from the skilled nursing facility to home, assisted living, or other care settings.

This role works closely with the interdisciplinary team, residents, families, and external partners to develop discharge plans that meet individual needs and ensure continuity of care.

Key Responsibilities:


* Collaborate with physicians, nursing, therapy, and social services to assess discharge needs starting at admission.


* Develop individualized discharge plans based on the resident's medical condition, care goals, and available support systems.


* Coordinate referrals and transitions to home health, hospice, assisted living, long-term care, or community-based services.


* Educate residents and families on post-discharge care plans, medications, equipment, and follow-up appointments.


* Arrange transportation and home equipment delivery, ensuring all resources are in place prior to discharge.


* Ensure timely and accurate documentation in the medical record and compliance with all federal, state, and facility guidelines.


* Monitor and follow up on resident readmissions and work with the care team on readmission prevention strategies.


* Participate in care conferences and interdisciplinary team meetings.


* Maintain ongoing communication with residents, families, and care team members regarding discharge progress and barriers.


* Serve as a liaison with hospitals, case managers, insurance companies, and community resources to ensure seamless transitions.


* Support long-term residents with transition planning when appropriate, including changes in level of care or payer source.

Qualifications:


* Minimum 1-2 years of experience in discharge planning, care coordination, or case management, preferably in a SNF or hospital setting.


* Knowledge of Medicare, Medi-Cal, and managed care discharge requirements and services.


* Excellent communication, organizational, and problem-solving skills.


* Ability to work collaboratively in a team-oriented environment.


* Familiarity with EMR systems and documentation standards.


* Strong understanding of community resources and post-acute care services.

Working Conditions:


* Standard SNF environment with resident interaction.


* Requires frequent walking, sitting, standing, and occasional lifting.


* Must be able to manage multiple priorities and deadlines.