**UPMC is seeking a Casual Discharge Plan Manager.** This role primarily involves working the day shift but may include some evenings until 8:00 p.m., as well as occasional weekends and holidays. Flexibility is a key requirement. The Discharge Plan Manager coordinates and is accountable for all post-discharge needs, acting as a financial steward for the hospital. This role involves assessing relevant factors, engaging with the care team, and focusing on an optimal discharge plan that ensures timely utilization of hospital resources. The optimal discharge plan reviews discipline recommendations and coordinates necessary care for positive patient outcomes outside of the inpatient setting. **Responsibilities:** + Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to achieve optimal outcomes. Consider the patient/family/caregiver’s level of health literacy. + Evaluate the patient/family/caregiver’s understanding and engagement with progress toward goals, incorporating findings into the plan of care. Balance resources with patient preferences and goals of care. + Assess the potential impact of social determinants of health that may elevate the risk of a poor transition. + Complete detailed assessments on every patient to understand medical and social factors, determine the patient’s capacity for self-care, identify support systems, outline barriers to discharge, and determine the likelihood of requiring post-hospital services and their availability. Continually reassess the 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, their capabilities, and capacities, as well as various types of service providers available. Ensure appropriate arrangements for post-hospital care are made before discharge to avoid unnecessary delays. + Integrate patients’ goals, the healthcare team’s assessment, risks, and available resources to develop and coordinate a successful transition plan. + Engage in clear communication with the patient/member/caregivers and the interdisciplinary care team 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, and outstanding orders into the discharge plan, and monitor, revise, and respond to the progression of discharge milestones. + Serve as a contact between hospitals and post-hospital care facilities, as well as the physicians who provide care in either or both settings. + Recognize and demonstrate shared accountability in developing a discharge plan with the patient/member/caregiver and team members to ensure optimal outcomes. + Align practice with the mission, vision, and values of the organization. Adhere to ethical standards and codes of conduct of applicable professional organizations and UPMC. Maintain clinical knowledge and ensure compliance with regulatory requirements. + Advocate on behalf of patients/family/caregivers for service access and the protection of the patient’s health, well-being, safety, and rights. + Manage the 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 the patient medical chart. + Provide staff orientation and mentoring as appropriate. + **Nursing Pathway:** + Diploma or associate degree in nursing. + Active Registered Nurse (RN) license. + At least one year of experience in discharge planning or care coordination. **OR** + **Social Work/Health Services Pathway:** + Bachelor’s degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of those being served. + Master’s degree preferred. + At least one year of experience in discharge planning or care coordination. **Knowledge and Skills:** + Proficient in navigating communications with payer sources and programs. + Knowledge and understanding of regulatory guidelines. + Skilled in planning, organization, follow-up, control, and delegation. + Strong problem-solving abilities, self-development, and organizational competencies. + Ability to read, understand, analyze, and interpret medical record documents. + Capable of applying principles of logic and critical thinking to a wide range of problems and dealing with various abstract and concrete variables. + Demonstrates the ability to function independently, taking initiative to proactively drive a discharge plan while working with a multidisciplinary team. + Ability to lead care teams to develop and execute safe and efficient discharge plans. + Knowledgeable about area resources, their capabilities, and capacities, as well as various types of service providers available. + Understanding of inpatient care setting operations. + Ability to manage multiple priorities in a fast-paced environment. **Licensure, Certifications, and Clearances:** + Registered Nurses must maintain an active RN license. **OR** + For those without an active RN license, an LBSW (Licensed Bachelors Social Work) or other related healthcare professional license is required. + CCM (Certified Case Manager) or ACM (Accredited Case Manager) or other nursing or social work certification preferred. **Accepted Licenses:** + Licensed Bachelors Social Work (LBSW) + Licensed Clinical Social Worker (LCSW) + Licensed Social Worker (LSW) + Other Healthcare Professional Licenses for Discharge Planning + Registered Nurse (RN) + Act 34 Clearance _Current licensure is required either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is located will have 60 days upon changing their residency to apply for licensure within that state._ **UPMC is an Equal Opportunity Employer/Disability/Veteran**