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Are you an RN or Social Worker interested in care management, case management, or care coordination?

UPMC Western Maryland is proud to announce the new Clinical Care Coordination and Discharge Planning team, dedicated to caring for patients throughout their treatment journey.

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.

The shift will be a varied schedule between the hours of 7:30 am - 5:30 pm. Includes rotating weekends and holidays.

*Candidates will be hired into the appropriate job title depending on education and experience. Pay rates shown are for the Discharge Planning Associate job title.

Become part of a multi-disciplinary 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 $3,000 sign-on bonus for eligible roles with a two-year commitment

• A designated career ladder designed to support career advancement, with two track to support both nurses and social workers

• $3,000/year in tuition assistance to help you get where you want to be

• And much more!

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.

• Provide staff orientation and mentoring as appropriate.

• RN Requirements: Diploma or Associate's Degree in Nursing.

• Social Worker Requirements: 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 required.

• Experience: No experience in discharge planning/care coordination. Clinical/patient-facing experience preferred.

• Knowledge and Skills: Excellent communication skills are required. Must be skilled in planning/organization, follow-up/control, problem-solving, self-development orientation, and organizational behaviors/competencies. Must possess the ability to apply principles of logic and critical thinking to a wide range of problems and to deal with a variety of abstract and concrete variables. Comfortable working both independently and as a team member. Proficient computer skills.

Licensure, Certifications, and Clearances:

• Registered Nurses employed in this position are required to maintain active RN license

• No license required for Social Workers

UPMC is an Equal Opportunity Employer/Disability/Veteran