UPMC Presbyterian Shadyside seeks a Social Worker – Discharge Plan Manager to coordinate all post-hospital discharge needs; act as financial steward for the hospital; identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process for optimal outcomes; evaluate patient/family/caregiver level of understanding and engagement with the progress toward goals and incorporate findings into the plan of care; complete detailed assessment on every patient 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; facilitate teams to develop and execute safe and efficient discharges; maintain knowledge of area resources and various types of service providers available; ensure appropriate arrangements for post-hospital care before discharge; integrate patients' goals, the health care team's assessment, risks and available resources in order to develop and coordinate a successful transition plan; serve as a liaison between the patient and the care team; 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 and the physicians who provide care in either or both settings; adhere to ethical standards and codes of conduct and maintain clinical knowledge of/ensure compliance with regulatory requirements; incorporate innovation and technology and document care in patient medical chart; assist in operational activities for the department including staff orientation, mentoring, or training and perform other duties as needed.

　　Job Responsibilities:

　　· Coordinate all post-hospital discharge needs.

　　· Act as financial steward for the hospital.

　　· Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process for optimal outcomes.

　　· Evaluate patient/family/caregiver level of understanding and engagement with the progress toward goals and incorporate findings into the plan of care.

　　· Complete detailed assessment on every patient 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.

　　· Facilitate teams to develop and execute safe and efficient discharges.

　　· Maintain knowledge of area resources and various types of service providers available.

　　· Ensure appropriate arrangements for post-hospital care before discharge.

　　· Integrate patients' goals, the health care team's assessment, risks and available resources in order to develop and coordinate a successful transition plan.

　　· Serve as a liaison between the patient and the care team.

　　· 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 and the physicians who provide care in either or both settings.

　　· Adhere to ethical standards and codes of conduct and maintain clinical knowledge of/ensure compliance with regulatory requirements.

　　· Incorporate innovation and technology and document care in patient medical chart.

　　· Assist in operational activities for the department including staff orientation, mentoring, or training and perform other duties as needed.

　　Master’s degree, or equivalent, in Social Work or related Health and Human Services field;

　　Must hold LCSW, CCM/ACM or other social work certification.

　　UPMC is an Equal Opportunity Employer/Disability/Veteran