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UPMC is launching a new **Clinical Care Coordination and Discharge Planning team** aimed at enhancing patient care throughout their treatment journey. This team will integrate the roles of **RNs and social workers** , who will work equally in discharge planning and serve as central points of contact alongside Physicians or APPs.

Key benefits for team members include:

+ **Career advancement** opportunities with a designated career ladder for both nurses and social workers.

+ **Flexible schedules** to accommodate personal needs.

+ **Generous paid time off** : up to 5 ½ weeks plus 7 paid holidays.

+ **Tuition assistance** : up to $6,000/year.

Shift **=** Casual

Responsibilities:

+ Work with patients throughout their treatment journey — from day one of admission to post-discharge — to ensure patients are prepared for a successful discharge and achieve continued improvement following inpatient care.

+ Advocate on behalf of patient/family/caregivers for access to services and for protecting the patient's health, well-being, safety, and rights.

+ Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes.

+ Complete detailed patient assessments to determine patients' capacity for self-care, identify support systems, outline barriers to discharge, and determine the likelihood that patients will require post-hospital services and the availability of those services.

+ Collaborate with a multidisciplinary team to coordinate an individualized, safe, efficient care plan. Integrate patients' goals, the health care team's assessment, risks, and available resources to develop and coordinate a successful transition plan.

+ Serve as a liaison between patients and the care team. Incorporate discipline-specific recommendations, test results, and outstanding orders into the discharge plan and respond to the progression of discharge milestones.

+ Maintain knowledge of resources in the area, their capabilities and capacities, and service providers available. Ensure appropriate arrangements for post-hospital care will be made before discharge and work to avoid unnecessary delays in discharge.

+ Serve as a contact between hospitals and post-hospital care facilities and the physicians who provide care in both settings.

Nurse track: Diploma or Associate's Degree.

Non-nurse track: Bachelor's degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of those being served required. Master's degree preferred

Experience: No experience in discharge planning/care coordination. Clinical/patient-facing experience preferred.

Knowledge and Skills: Excellent communication skills required. Must be skilled in planning/organization, follow up/control, problem solving, self-development orientation, organizational behaviors/competencies. Must possess the ability to apply principles of logic and critical thinking to a wide range of problems and to deal with a variety of abstract and concrete variables. Comfortable working both independently and as a team member. Proficient computer skills.

Licensure, Certifications, and Clearances:

Nurse track: RN License required. Non-nurse track: No license required.

+ Act 33 with renewal

+ Act 34 with renewal

+ Act 73 FBI Clearance with renewal