Discharge Planner II, Social Services

Valley Health

. Provide holistic patient assessments and develop individualized care plans addressing social, emotional, medical, spiritual, and physical needs .

Posted 10/27/2026full-timeWinchester • Virginia • United StatesJuniorMid-Level💰 $26 - $40 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in holistic patient assessments and individualized care planning, ensuring compliance with Medicare and Medicaid requirements. Proficient in crisis intervention, interdisciplinary collaboration, and effective communication with patients, families, and healthcare teams.

Highest-signal resume keywords

Bachelor's Degree In Social WorkMedical Social Work ExperienceBLS CertificationKnowledge Of Discharge Planning ProcessesStrong Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Holistic Patient AssessmentIndividualized Care PlansCrisis InterventionPsychosocial AssessmentsSubstance Abuse AssessmentDocumentation SkillsKnowledge Of Abuse IndicatorsMedicaid ScreeningInterdisciplinary Care CoordinationThird-Party Reimbursement Knowledge

Soft Skills

Strong Interpersonal SkillsCritical ThinkingCreative Problem-SolvingFlexibilityTime Management

Tools & Technologies

Windows-Based ProgramsMicrosoft WordEmail

Certifications & Qualifications

BLS Certification

Industry Keywords

Medicare ComplianceMedicaid ProcessesPatient Discharge PlanningCommunity ResourcesLegal Processes For Guardianships

About the role

Key responsibilities & impact

Provide holistic patient assessments and develop individualized care plans addressing social, emotional, medical, spiritual, and physical needs
Ensure safe, timely discharges for medically and socially complex patients
Coordinate patient care with clinical partners to achieve realistic and desirable outcomes
Develop, implement, communicate, and document discharge plans for medically complex cases
Facilitate interdisciplinary care planning meetings and delegate tasks to support team members
Utilize post-acute care facilities and collaborate with financial partners for discharge planning
Conduct psychosocial assessments to identify long-term care needs and barriers to discharge
Provide crisis intervention and emotional support for patients and families
Assess substance abuse, advanced directives, and medical decision-making needs; assist with related forms
Educate patients and families on community resources and assist with referrals
Maintain contact with referral sources until resources are confirmed
Coordinate legal processes for guardianships, adoptions, advance directives, and protective services
Make timely referrals to CPS/APS as required by state law and testify in court when necessary
Ensure compliance with Medicare, Medicaid, and commercial insurance requirements for post-acute care
Complete Medicaid screening paperwork and maintain accurate documentation
Communicate with patients, families, physicians, and care teams to support transitions of care
Partner with leadership to address discharge delays, barriers, and emerging trends
Perform other duties as assigned

Requirements

What you’ll need

Bachelor’s degree from an accredited social work program or equivalent required
Master’s degree from an accredited social work program or equivalent is preferred
(2) years of previous social work in a medical setting is required
BLS Certification (Basic Life Support) - American Heart ‘Healthcare Provider’ (HCP) - AHA approved required
Ability to recognize, identify, and report signs and symptoms of suspected abuse and/or neglect
Knowledge of abuse/neglect indicators and reporting requirements
Knowledge of stages of human growth and development across neonate, pediatric, adult, and geriatric populations
Familiarity with third-party reimbursement, Medicaid processes/plans for Virginia and West Virginia, and discharge planning processes
Knowledge of funding, resources, services, clinical standards, and outcomes
Strong verbal and written communication skills
Ability to interact and collaborate effectively within a multidisciplinary team
Excellent interpersonal skills with all levels of internal and external customers
Demonstrated critical thinking and creative problem-solving abilities
Ability to be innovative and flexible in responding to rapidly changing needs and priorities
Proficient organizational and planning skills
Ability to work independently, manage multiple priorities, tolerate frequent interruptions, and handle a demanding workload
Self-directed with strong time management capabilities
Experience with computer technology, including Windows-based programs, email, and Microsoft Word

Benefits

Comp & perks

A Zero-Deductible Health Plan
Dental and vision insurance
Generous Paid Time Off
Tuition Assistance
Retirement Savings Match
A Robust Employee Assistance Program to help with many aspects of emotional wellbeing
Membership to Healthy U: An Incentive-Based Wellness Program
Health savings account
Flexible spending account for childcare
Life insurance
Short-term and long-term disability
Professional development
Discounts to on-campus dining