Discharge Planner

Job Title: Discharge Planner
Department: Social Services
Reports To: Social Services Director
Location: Loveland, Colorado
Employment Type: Full-Time

Position Summary

The Discharge Planner is responsible for coordinating safe and timely discharges for residents completing their skilled nursing stay. This role ensures residents transition smoothly to the most appropriate next level of care or home setting by assessing needs, arranging necessary post-discharge services, and collaborating with the interdisciplinary team to promote positive outcomes and prevent readmissions.

Key Responsibilities

• Conduct comprehensive discharge assessments for residents nearing the end of their skilled nursing stay, including evaluation of medical, functional, psychosocial, and environmental needs.
• Develop individualized discharge plans in collaboration with the resident, family members, physicians, therapists, social workers, and other members of the interdisciplinary care team.
• Identify and coordinate appropriate post-discharge services, including but not limited to:
• Home health care (skilled nursing, therapy, aide services)
• Durable medical equipment (DME) and supplies
• Outpatient therapy or rehabilitation services
• Transportation arrangements
• Medication management and delivery
• Community resources, meal programs, or caregiver support
• Assisted living, long-term care, or other residential placements when needed
• Ensure discharges are safe, appropriate, and aligned with the resident’s goals, preferences, and medical stability.
• Facilitate communication between the facility, external providers, insurance companies, and families to secure authorizations and confirm service arrangements.
• Complete all required documentation accurately and timely, including discharge summaries, care transition notes, and required regulatory forms (e.g., PASRR, MOON, etc. as applicable).
• Educate residents and families on discharge instructions, medication regimens, follow-up appointments, warning signs, and available resources.
• Participate in weekly interdisciplinary team meetings to discuss discharge readiness and potential barriers.
• Monitor for potential readmission risks and implement strategies to support successful community transitions.
• Maintain current knowledge of community resources, Medicare/Medicaid guidelines, and insurance requirements related to post-acute care transitions.
• Assist with appeals or insurance denials when related to discharge planning.

Qualifications

Required:

• Minimum of 1–2 years of experience in discharge planning, case management, or care coordination, preferably in a skilled nursing facility (SNF), hospital, or post-acute care setting.
• Strong knowledge of post-acute care options, community resources, and insurance/Medicare guidelines.
• Excellent communication, organization, and problem-solving skills.
• Ability to work collaboratively with an interdisciplinary team and build rapport with residents and families.
• Proficiency in electronic medical records (EMR) systems and Microsoft Office.

Preferred:

• Certified Case Manager (CCM) or other relevant certification.

Skills & Competencies

• Compassionate and resident-centered approach to care.
• Ability to manage multiple priorities and meet tight timelines in a fast-paced environment.
• Strong attention to detail and commitment to regulatory compliance.
• Problem-solving mindset with the ability to address complex discharge barriers creatively.

Physical Requirements

• Ability to sit, stand, and walk for extended periods.
• Occasional lifting or moving of residents (with assistance) during assessments.
• Visual and auditory acuity sufficient to perform job duties.

Pay: $26.00 - $30.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Health savings account
• Paid time off
• Vision insurance

Work Location: In person