Discharge Planner, Behavioral Health in Norwalk, CA at Pipeline Health

Date Posted: 1/7/2023

Job Snapshot

  • Employee Type:
  • Location:
    Norwalk, CA
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:

Job Description

Discharge Planner Behavioral Health Unit

The Discharge Planner provides a broad range of support services to the RN Care Coordinators and Clinical Social Workers with their transition planning activities. These activities include referrals to post-acute agencies, scheduling discharge appointments for primary care specialists or clinics, and clerical activities as needed.

The Discharge Planner is responsible to document all discharge planning activities appropriately in the medical record. Work is performed under the direct supervision of the Lead Discharge Planner.

Primary Duties and Responsibilities

Assists patients to acquire resources for housing, food, insurance, public entitlements, legal representation, and other community resources in collaboration with the Social Worker and/or RN Care Coordinator.

Makes post-discharge appointments in collaboration with the patient/family, and performs follow-up on post-discharge matters as required.

Evaluates patient needs/requests; reports observation and brings urgent and/or crisis situations to the attention of the case management team/leadership immediately.

Consults and cooperates with other professionals and agency personnel to aid them in recognizing the significant social components of health care and understanding their impact on patients and their families.

Demonstrates a culturally sensitive approach to patients and families

Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits.

Conducts assessments to identify barriers and opportunities for intervention.

Develops care plans that align with the physician’s treatment plans and recommends interventions that align with proposed goals.

Generates referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement.

Collaborates with provider doctors, social workers, discharge planners, and community based service providers to coordinate care accordingly.

Coordinates and facilitates with the multi-disciplinary health care team as necessary in order to ensure care plan goals are achieved and maximize member outcomes.

Assists in identifying opportunities for alternative care options based on member needs and assessments.

Evaluates service authorizations to ensure alignment and execution of the member’s care and physician treatment plan.

Contributes to corporate goals through ongoing execution of member care plans and member goal achievement.

Documents all encounters with providers, members, and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates care plans based on member needs, as appropriate.   

Additional duties as assigned.

Preferred Qualifications:

Strong interpersonal and assessment skills, especially the ability to relate well with seniors, their families, and community care providers, along with demonstrated ability to handle rapidly changing crisis situations.

Fluency in Spanish

Relevant work experience preferably as a Care Manager or Discharge Planner

Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Proficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systems


8 hour shift

Day shift