Discharge Planner- ONSITE

Job Overview

The Discharge Planner plays an essential role in patient outcomes, serving as the core bridge between providers, facility care teams, patients, and their families. This role is responsible for facilitating seamless patient transitions across healthcare settings by developing effective partnerships, assessing social determinants of health, and deploying comprehensive, patient-centered plans of care.

Pay & Job Type

Pay: $22-$31 per hour (Estimated based on cross-role alignment)

Job Type: Full-time

Schedule: 8-hour shift, Monday to Friday

Location: Based out of Homewood, IL and Glenwood, IL

Roles & Responsibilities

Care Transition & Planning

• Work closely with clinical teams to deploy patient plans of care.
• Help support patients and caregivers with transitions to the next level of care, including facilitating follow-up appointments and communicating care plans to incoming providers.

Assessment & Risk Identification

• Conduct patient social risk factor assessments.
• Evaluate unmet health and social needs and anticipate potential gaps in post-discharge care.
• Identify high-risk, complex patients who would benefit from transitional care services, chronic care management, or remote patient monitoring.

Collaboration & Interdisciplinary Communication

• Communicate daily and collaborate with patients, families, Nurse Case Managers, Physicians, and facility staff.
• Attend interdisciplinary team (IDT) care plan meetings at facilities.

Patient Advocacy & Education

• Serve as the primary point of contact, advocate, and informational resource for families and community resources.
• Provide education to improve health literacy regarding patient conditions, treatment plans, and managing post-discharge care.

Documentation & Data Collection

• Assist in chart creation and data entry of patient demographics and diagnoses.
• Assist in the data collection of key quality metrics and program performance improvement metrics.

Skills & Qualifications

Compliance & Technical Skills

• Process and maintain all patient records in strict compliance with HIPAA.
• Proficiency with Electronic Medical Records (EMR), basic typing, and Google Workspace applications.

Core Competencies

• Strong critical thinking, problem-solving, and organizational skills with sharp attention to detail.
• High adaptability, effective time management, and a passion for patient care.

Communication

• Exceptional communication skills across all modes (written, verbal, and interpersonal) with a proven ability to provide kind and professional support.

Education & Experience Requirements

Education

• High school diploma or equivalent required.
• Associate's or Bachelor's degree preferred in Medical Health Sciences.

Experience

• Minimum 1-2 years of experience in Care Coordination, Case Management, or Transitional Care.
• Minimum 1-2 years of experience working with medical terminology.
• Experience working with older adults is highly preferred/required.

Benefits

• 401(k) with company matching
• Comprehensive Health, Dental, and Vision insurance
• Health Savings Account (HSA)
• Life insurance
• Paid Time Off (PTO)

At Community Physicians, we are a dedicated, multi-specialty medical group focused on providing exceptional, relationship-based care to older adults in skilled nursing and post-acute settings. Our mission is to improve health outcomes, enhance care transitions, and preserve the dignity of every patient we serve.

Why You Should Join Us?

1. Purpose-Driven Work:

You will play a vital role in caring for medically complex older adults during their most vulnerable health transitions. Your expertise will directly impact patient outcomes, reduce hospital readmissions, and improve quality of life.

2. Collaborative and Supportive Environment:

We believe in the power of partnership. You’ll work closely with facility staff, families, and interdisciplinary teams to ensure seamless, compassionate, and coordinated care.

3. Clinical Excellence and Innovation:

We prioritize evidence-based practices and continuity of care, bringing clinical excellence to every bedside. Our model allows you to practice meaningful medicine while making a tangible difference in patients’ lives.

4. Professional Growth and Leadership:

As part of our team, you’ll have opportunities to lead, innovate, and contribute to the growth of geriatric care in our community. We invest in our providers’ development and support their journey toward excellence.

5. A Culture of Compassion and Respect:

We are committed to treating every patient with dignity, empathy, and respect-and we extend that same commitment to our team. Here, you’ll be part of a culture that values each member’s contribution and well-being.