Please mention DailyRemote when applying
See how much of this job your resume covers, and what’s missing.
Want a recruiter to go through it line by line?
Get professional reviewUpload your resume and we draft a letter for this exact role, tailored to what it asks for.
Coordinates discharge planning and care transition activities for hospitalized patients to ensure safe and timely transitions. Collaborates with interdisciplinary teams to arrange post-acute services and educate patients and caregivers on discharge instructions.
Job Description Summary
Hours & Location:
How will you make an impact & Requirements
Key Responsibilities
• Assess patients' discharge planning needs through review of medical records, interdisciplinary collaboration, patient interviews, and evaluation of clinical, functional, psychosocial, and environmental factors affecting post-discharge care.
• Develop and coordinate individualized discharge plans that align with physician orders, patient goals, payer requirements, and available community resources.
• Collaborate with hospitalists, nursing staff, case managers, therapists, pharmacists, social workers, and ancillary departments to coordinate timely, safe, and effective patient discharges.
• Arrange post-acute services including home health, skilled nursing facilities, rehabilitation services, durable medical equipment, hospice, outpatient therapies, transportation, and community-based resources as appropriate.
• Educate patients and caregivers regarding discharge instructions, medications, follow-up appointments, disease management, warning signs requiring medical attention, and available community resources.
• Identify barriers to discharge including insurance authorization delays, transportation needs, caregiver limitations, equipment availability, housing concerns, or social determinants of health, and coordinate appropriate interventions.
• Communicate with primary care providers, specialists, post-acute providers, payers, and external agencies to facilitate continuity of care and reduce avoidable readmissions.
• Document discharge planning assessments, care coordination activities, referrals, patient education, and transition plans accurately within the electronic health record in accordance with organizational standards and regulatory requirements.
• Monitor discharge timelines, transition metrics, and assigned patient caseloads while supporting organizational goals related to length of stay, readmission reduction, patient satisfaction, and quality outcomes.
• Participate in interdisciplinary rounds, quality improvement initiatives, patient safety activities, and care transition programs that improve discharge processes and patient outcomes.
Benefits:
Why Millennium?
Millennium Physician Group is one of the largest comprehensive primary care practices with healthcare providers throughout Florida.
At Millennium Physician Group, you will find an organization that focuses on family and building a strong network of people to care for the communities we serve. We are always searching for employees who have a strong customer service attitude, fantastic teamwork skills and a willing smile ready to share.
Our promise is to provide you with the tools to do your job successfully, as well as providing a team atmosphere that empowers you to seek better ways to deliver care to our patients and their families. We also promise to care for you as an individual, and help you grow in your role with Millennium Physician Group.
If you are interested in joining an organization that puts an emphasis on team work and family, then Millennium Physician Group is the right choice.
• Maintain knowledge of applicable regulatory requirements, Medicare Conditions of Participation, payer guidelines, post-acute care resources, and evidence-based transition-of-care practices.
Compensation Range:
$52,877.00to
$79,316.00
The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.
Stop the endless job search. Our AI finds and applies to the best jobs for you.
Featuring 225,369+ Jobs in Others
Answer easy questions
225,369+ jobs across 15+ categories
Get your best job matches
Only hand-screened, legit jobs
Find a remote job faster
No ads, scams, or junk
“I was the first applicant for a remote marketing position that got listed on the company website the same day I applied. Had an interview within 48 hours!”