Discharge Plan Manager

Are you an RN or social worker interested in care management, case management, or care coordination? UPMC Altoona is seeking a full-time Discharge Plan Manager to join the Clinical Care Coordination and Discharge Planning team, dedicated to caring for patients throughout their UPMC treatment journey. This position will work Monday through Friday, 8am - 4:30pm, with rotating weekends and holidays.

In this 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.

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 $6,000 sign-on bonus for eligible roles with a two-year work commitment
• 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!

**Individuals will be hired into the appropriate job title and salary within the Discharge Planning career ladder, based on experience and education.

Responsibilities:

Assessment & Care Planning

• Identify clinical, psychosocial, historical, financial, cultural, and spiritual factors that shape the discharge plan.
• Consider patient/family/caregiver health literacy, understanding, and engagement when developing the plan of care.
• Evaluate the influence of social determinants of health and their impact on transition risks.
• Complete comprehensive assessments to determine self‑care capacity, support systems, barriers to discharge, and need for post‑hospital services.
• Continually reassess the discharge plan in response to changing clinical or social factors.

Care Coordination & Discharge Execution

• Lead interdisciplinary teams in developing and executing safe, efficient discharge plans.
• Maintain knowledge of local resources, service providers, and their capabilities.
• Ensure appropriate post‑hospital arrangements are made prior to discharge and avoid unnecessary delays.
• Integrate patient goals, clinical assessments, risks, and available resources to support a smooth transition.
• Serve as a liaison between the hospital, post‑hospital facilities, and involved physicians.

Communication & Collaboration

• Communicate clearly with patients, caregivers, and the interdisciplinary care team to build individualized discharge plans.
• Collaborate with attending practitioners, nurses, and other team members to coordinate care.
• Incorporate discipline‑specific recommendations, test results, and outstanding orders into the discharge plan.
• Monitor progression toward discharge milestones and adjust plans as needed.
• Promote shared accountability in developing a patient‑centered discharge plan.

Advocacy, Ethics & Compliance

• Advocate for patient safety, well‑being, rights, and access to needed services.
• Align practice with the organization’s mission, vision, values, and applicable ethical standards.
• Maintain clinical knowledge and ensure compliance with all regulatory requirements.

Quality, Outcomes & Resource Stewardship

• Balance cost of care with patient safety, clinical quality, risk, and satisfaction to support optimal outcomes.
• Incorporate innovation and technology to strengthen care coordination and transitions.
• Document all planning activities and updates in the medical record.

Professional Development & Support

• Provide staff orientation, mentoring, and support as appropriate.

• Diploma or associate degree in nursing and active Registered Nurse license; OR 

  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. 

• Master's degree preferred. 
• At least one year of experience in discharge planning/care coordination required.

Additional Qualifications:

• Must possess knowledge in navigating communications with payer sources and programs.
• Possess knowledge and understanding of regulatory guidelines.
• Must be skilled in planning/organization, follow up/control, delegation. 
• Problem solving, self-development, organizational behaviors/competencies.
• Must be able to read, understand, analyze, and interpret medical record documents.
• 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.
• Demonstrate ability to function independently, taking initiative to be proactive and drive a discharge plan while working with a multi-disciplinary team.
• Be able to lead care teams to develop and execute safe and efficient discharge plans.
• Maintain knowledge about area resources and their capabilities and capacities as well as various types of service providers available. 
• Demonstrate understanding of inpatient care setting operations.
• Ability to manage multiple priorities in a fast-paced environment.

Licensure, Certifications, and Clearances:

• Licensed Bachelors Social Work (LBSW) OR Licensed Clinical Social Worker (LCSW) OR Licensed Social Worker (LSW) OR Other Healthcare Professional Licenses for Discharge Planning OR Registered Nurse (RN)
• Registered Nurses employed in this position are required to maintain active RN license. 
• Those without an active RN license, an LBSW or other related healthcare professional license required. 
• CCM or ACM or other nursing or social work certification preferred.
• Act 34

*Current licensure 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 also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran