Description
Coordinate safe, timely hospital discharges by assessing psychosocial and post-acute needs, educating patients and families, arranging services and equipment, and resolving barriers to care transitions. Collaborate with the healthcare team and payers, connect patients to community resources and benefits, and ensure regulatory and documentation requirements are met.
- • Collaborate with physicians, nurses, therapists, and payers to assess discharge readiness and needs.
- • Conduct psychosocial and functional assessments to determine post-acute care and support requirements.
- • Identify home, financial, transportation, and social barriers through interviews and chart review.
- • Develop individualized discharge plans using clinical data, patient goals, and payer criteria.
- • Arrange referrals to home health, skilled nursing, rehabilitation, hospice, and community resources.
- • Coordinate durable medical equipment, home services, and transportation for safe transitions.
- • Schedule follow-up appointments and ensure warm handoffs to primary, specialty, and community providers.
- • Educate patients and caregivers on discharge plans, care options, and available supports.
- • Facilitate family meetings and care conferences to align goals of care and discharge plans.
- • Advocate for patients to resolve barriers to placement, coverage, or service access.
- • Obtain insurance authorizations and complete required Medicare/Medicaid notices and documentation.
- • Adjust discharge plans as patient condition, supports, or coverage change.
- • Monitor, document, and report progress toward discharge milestones and outcomes in the medical record.
- • Ensure transition information and orders are communicated to receiving providers.
- • Participate in readmission reduction, patient flow, and care transition quality initiatives.
- • Adhere to hospital, regulatory, and privacy policies; maintain accurate records.
- • Screen for safety risks and social determinants; escalate protective concerns per policy.
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Healthcare & Human Services
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Tasks & skills:
O*NET occupational data (work activities, skills, knowledge).
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Last reviewed: Jan 2026
