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Are you an RN or Social Worker passionate about care coordination and supporting patients through complex treatment journeys? UPMC Altoona is seeking a full-time Discharge Plan Manager to support the Radiation Oncology department, dedicated to guiding patients through safe, seamless transitions beyond their radiation treatment.

The Discharge Plan Manager plays a key role in supporting patients as they transition beyond treatment. In this role, you'll take the lead on all post‑discharge needs - assessing relevant clinical and social factors, collaborating with the care team, and ensuring timely, appropriate use of hospital resources. You'll develop individualized discharge plans by reviewing discipline recommendations and coordinating the services that help patients thrive outside the inpatient setting.

This full‑time position (Monday-Friday, 8am-4:30pm) partners closely with physicians, APPs, nurses, therapists, and support staff to guide patients through the next steps of their care journey. As the first Discharge Plan Manager in Radiation Oncology, you'll have the unique opportunity to shape processes, strengthen communication pathways, and elevate the continuity of care for patients navigating cancer treatment. It's a chance to build something meaningful and to make a direct impact on patient experience.

Join a multidisciplinary environment where collaboration, innovation, and patient‑centered care drive every decision. This is an opportunity to build a progressive discharge planning model within Radiation Oncology, supported by UPMC's commitment to excellence and professional growth.

Responsibilities:

Patient Assessment & Care Planning

+ Assess clinical, psychosocial, financial, cultural, and spiritual factors that influence discharge needs.

+ Evaluate patient and caregiver health literacy, understanding of the care plan, and engagement in goals.

+ Identify barriers to discharge, support systems, and the patient's capacity for self‑care.

+ Reassess the discharge plan throughout the stay to ensure it remains appropriate and responsive to changing needs.

+ Consider social determinants of health that may increase risk during transitions of care.

Discharge Coordination & Transition Planning

+ Develop and coordinate safe, efficient, and timely discharge plans in collaboration with the care team.

+ Integrate patient goals, clinical recommendations, test results, and outstanding orders into the transition plan.

+ Ensure all necessary post‑hospital services are arranged prior to discharge and work to prevent avoidable delays.

+ Maintain up‑to‑date knowledge of community resources, service providers, and their capabilities.

Communication & Collaboration

+ Serve as a liaison between patients, caregivers, the interdisciplinary team, and post‑hospital providers.

+ Facilitate clear, consistent communication to support shared decision‑making and coordinated care.

+ Collaborate with attending practitioners, nursing, social work, and other disciplines to create individualized plans of care.

+ Monitor progress toward discharge milestones and adjust plans as needed.

External Partnerships

+ Act as a point of contact between the hospital, post‑acute facilities, and physicians involved in ongoing care.

+ Support smooth transitions by ensuring accurate, timely information exchange across settings.

Advocacy, Ethics & Compliance

+ Advocate for patient rights, safety, well‑being, and access to appropriate services.

+ Uphold organizational mission, values, and professional ethical standards.

+ Maintain current knowledge of regulatory requirements and ensure compliance in all discharge planning activities.

Resource Stewardship & Quality Outcomes

+ Balance patient preferences with available resources to support safe, cost‑effective care.

+ Manage utilization of services with attention to quality, risk, patient satisfaction, and financial stewardship.

+ Incorporate innovation and technology to enhance coordination, communication, and workflow efficiency.

Education Required:

+ Diploma or associate degree in nursing and active Registered Nurse license OR

+ 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 Required:

+ At least one year of experience in discharge planning/care coordination required.

Knowledge and Skills:

+ Must possess knowledge in navigating communications with payer sources and programs.

+ Possess knowledge and understanding of regulatory guidelines.

+ Must be skilled in planning/organization, follow up/control, delegation.

+ Problem solving, self-development, organizational behaviors/competencies.

+ Must be able to read, understand, analyze, and interpret medical record documents.

+ 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.

+ Demonstrate ability to function independently, taking initiative to be proactive and drive a discharge plan while working with a multi-disciplinary team.

+ Be able to lead care teams to develop and execute safe and efficient discharge plans.

+ Maintain knowledge about area resources and their capabilities and capacities as well as various types of service providers available.

+ Demonstrate understanding of inpatient care setting operations.

+ Ability to manage multiple priorities in a fast-paced environment.

Licensure, Certifications, and Clearances:

+ Licensure Requirements: Registered Nurse (RN), Licensed Bachelors Social Work (LBSW), Licensed Clinical Social Worker (LCSW), Licensed Social Worker (LSW), or Other Healthcare Professional Licenses for Discharge Planning

+ Registered Nurses employed in this position are required to maintain active RN license.

+ Those without an active RN license must have an LBSW, LCSW, LSW, or other related healthcare professional license.

+ CCM or ACM or other nursing or social work certification preferred.

+ Act 34

*Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran