Discharge Planner, Social Services

Valley Health

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

Posted 11/2/2026full-timeWinchester • Virginia • United StatesMid-LevelSenior💰 $26 - $40 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in holistic patient assessments, individualized care planning, and interdisciplinary collaboration to ensure safe and timely patient discharges. Proficient in crisis intervention, psychosocial assessments, and compliance with healthcare regulations.

Highest-signal resume keywords

Holistic Patient AssessmentsIndividualized Care PlansCrisis InterventionBLS CertificationInterdisciplinary Collaboration

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Psychosocial AssessmentsDischarge PlanningSubstance Abuse AssessmentMedicaid ScreeningDocumentation Accuracy

Soft Skills

Strong Verbal CommunicationStrong Written CommunicationCritical ThinkingCreative Problem-SolvingOrganizational Skills

Tools & Technologies

Windows-Based ProgramsMicrosoft WordEmail

Certifications & Qualifications

BLS Certification

Industry Keywords

Medicare ComplianceMedicaid ProcessesInterdisciplinary TeamsPatient Care CoordinationCommunity Resources

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 and interdisciplinary teams
Develop, implement, communicate, and document discharge plans
Facilitate interdisciplinary care planning meetings and delegate tasks to support team members
Utilize post-acute care facilities and collaborate with financial partners
Conduct psychosocial assessments to identify long-term care needs and barriers to discharge
Provide crisis intervention and emotional support to 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 CPS/APS referrals as required by state law and testify in court when necessary
Ensure compliance with Medicare, Medicaid, and commercial insurance requirements
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 is required
BLS Certification (Basic Life Support) - American Heart ‘Healthcare Provider’ (HCP) - AHA approved required; new hires must have appropriate certification prior to completion of orientation
Previous social work experience in a medical setting is preferred
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 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 collaborate within a multidisciplinary team
Critical thinking and creative problem-solving abilities
Organizational, planning, time management, and multitasking skills
Ability to work independently and tolerate frequent interruptions and a demanding workload
Experience with 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