Job Summary
Responsible for coordinating and managing discharge planning for patients admitted to the Withdrawal Management Unit (WMU) with substance use disorders and co-occurring medical and/or psychiatric conditions. Ensures safe, timely, and appropriate transitions to the next level of care based on ASAM criteria and individual patient needs.
Essential Functions
Works collaboratively with the interdisciplinary team and community providers to ensure continuity of care and successful recovery outcomes.
Discharge Planning & Care Coordination
Coordinate and implement individualized discharge plans for all WMU patients
Identify appropriate next level of care (e.g., residential, PHP, IOP, outpatient, MAT) based on clinical needs and ASAM recommendations
Schedule follow-up appointments prior to discharge with date, time, and provider documented
Facilitate referrals to community resources including:
Substance use treatment programs
Mental health services
Primary care providers
Housing and social support services
Continuity of Care
Ensure smooth transitions by coordinating with receiving facilities and providers
Transmit required clinical documentation to next level of care
Provide patient education on:
Discharge plan
Medication-assisted treatment (MAT) options
Relapse prevention strategies
Confirm patient understanding of follow-up instructions
Interdisciplinary Collaboration
Participate in daily multidisciplinary rounds
Communicate discharge barriers and collaborate with team to resolve
Work closely with:
Physicians
Nursing staff
Counselors
Case management
Length of Stay Awareness
Support timely discharge planning aligned with patient progress
Identify and address barriers early to prevent unnecessary delays
Assist team in maintaining appropriate patient flow within the unit
Documentation & Compliance
Document all discharge planning activities in the EMR in accordance with:
Hospital policy
Regulatory requirements (Joint Commission, CMS, NJ DOH)
Ensure documentation includes:
Discharge plan
Aftercare appointments
Patient education
Coordination efforts
Other Duties
The duties and responsibilities outlined above are not intended to be an exhaustive list. The employee may be required to perform additional tasks, responsibilities, or assignments needed to support the operations of the Withdrawal Management Unit and the organization. Duties may be modified or changed at any time, with or without notice, based on departmental and organizational needs.
Minimum Education/Certifications
- Associate or Bachelor’s degree in social work, Counseling, or related field
- Preferred: CADC/LCADC or equivalent addiction certification
- Knowledge of ASAM Criteria and substance use treatment continuum
- Strong communication and coordination skills
Minimum Work Experience
Minimum 2 years behavioral health or substance use disorder experience
At least 1 year in detox / withdrawal management or acute care setting preferred
Position Type/Expected Hours of Work:
Non-Exempt
Physical Requirements:
- Frequent walking and standing throughout the unit
- Ability to sit, bend, reach, and move between patient care areas
- Requires clear communication and observation skills
- Ability to work in a fast-paced environment and respond to patient needs promptly
Working Conditions:
Work is performed in an acute care hospital detox/withdrawal management unit with frequent exposure to patients experiencing:
- Active withdrawal symptoms (e.g., tremors, agitation, nausea, delirium risk)
- Substance intoxication and behavioral instability
- Co-occurring psychiatric conditions (anxiety, depression, psychosis)
Professional Field
Counseling
Nursing
Social Work
Other Behavioral, Mental, or Healthcare Field