Discharge PlannerOakland Community Health Network • Pontiac, MI, US

Discharge Planner

Oakland Community Health Network • Pontiac, MI, US

16 days ago

Job type

Full-time

Job description

Job Description

Job Summary

The Discharge Planner will be responsible for developing comprehensive discharge plans that address the mental health and substance use needs of clients, ensuring continuity of care and connection to community resources. This role includes assessing an individual’s readiness, coordinating post-discharge services, and collaborating with internal and external providers. The planner will educate individuals and families on available support and ensure all documentation meets regulatory standards.

This is a 24 / 7 facility with shifts available across all hours. Compensation is based on experience.

Essential Functions

Conduct thorough assessments of individual’s mental health, substance use, medical, and social needs to create individualized discharge plans
Collaborate with the treatment team, including physicians, therapists, social workers, and nurses, to ensure a holistic understanding of the patient's needs
Evaluate the individual’s readiness for discharge and address any barriers to a successful transition
Identify and arrange appropriate post-discharge resources, including outpatient therapy, substance use treatment programs, housing, support groups, vocational rehabilitation, and medical follow-up
Coordinate with community resources, mental health agencies, addiction recovery programs, and other support services
Develop a discharge plan that includes scheduling of follow-up appointments, transportation assistance, and ongoing communication with external providers
Provide education and guidance to individuals and families regarding the discharge plan, community resources, and strategies for managing mental health and substance use challenges
Ensure individuals and their families understand the importance of follow-up care and provide instructions for accessing services
Maintain detailed and accurate documentation of discharge planning activities, including assessments, care coordination efforts, and any referrals made
Ensure all discharge planning follows federal, state, and local regulations, as well as organizational policies
Monitor individual progress post-discharge and adjust plans as necessary
Act as a liaison between individuals, families, providers, and community resources
Participate in multidisciplinary team meetings to discuss discharge options and contribute to the treatment planning process
Provide crisis intervention services as needed to support the immediate needs of individuals during the discharge process
Other duties as assigned

Job Requirements and Qualifications

Education

Bachelor's or master's degree in social work, Counseling, Psychology, or a related field-Required

Training Requirements (licenses, programs, or certificates) :

CPR / BLS

Experience Requirements :

Experience : 2 years of experience in mental health, substance use treatment, or discharge planning in a hospital or community setting

Familiarity with community resources for mental health and substance use treatment

Job Specific Competencies / Skills :

Ability to work independently and as part of a team

Excellent organizational and time-management skills

Strong analytical and problem-solving skills

Ability to remain calm and focused under pressure

Empathy and strong ethical standards

Good documentation and record-keeping skills

Knowledge Requirements :

HIPPA

Microsoft 365

Recipient Right’s

Mental Health Code

Medicaid Manual

Regulatory compliance

Oakland Community Health Network’s Core Competencies :

Interacting with others in a way that gives them confidence in one’s intentions and those of the organization; demonstrating loyalty to the organization and its mission and values; maintaining social, ethical, and organizational norms; firmly adhering to codes of conduct and ethical principles. (Integrity / Building Trust)

Making customers and their needs a primary focus of one’s actions; developing and sustaining productive customer relationships, recognizing that the ultimate customer is the person served. (Customer Focus)

Actively identifying new areas for learning; regularly creating and taking advantage of learning opportunities; using newly gained knowledge and skill on the job and learning through their application. (Continuous Learning)

Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence in addition to consciously adopting organizational standards of excellence. (Work Standards)

Clearly conveying information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message. (Communication)

Additional Information

(Travel required, physical requirements, on-call schedules, etc.) :

Must have available means of transportation to and from OCHN and for required offsite meetings or site visits.

Must be available for meetings and events which may occur outside of standard office hours.

Work performed primarily in an office environment.

The ideal candidate must be able to complete all physical requirements of the job with or without a reasonable accommodation.

OCHN is committed to building a diverse team and fostering an inclusive and equitable culture. We are proud to be an equal opportunity employer that embraces and encourages our employees' differences. This includes (but is not limited to) ability, age, color, family type, gender expression and identity, individual expression, medical conditions, national origin, pregnancy, race, religion, sexual orientation, veteran status, and all other diverse and wonderful characteristics.

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Discharge Planner • Pontiac, MI, US