Social Service Planner Jobs (NOW HIRING)

The Discharge Planner is responsible for coordinating safe and effective resident transitions from the skilled nursing facility to the appropriate level of care. This role may be filled by a qualified Social Services professional or licensed nurse and works closely with residents, families, the interdisciplinary care team, and community providers to develop and coordinate individualized discharge plans.

Responsibilities include arranging post-discharge services, medical equipment, home health or other community resources, follow-up care, and additional services needed for a successful transition. The Discharge Planner supports residents and families throughout the discharge process while promoting continuity of care, regulatory compliance, and the prevention of avoidable hospital readmissions.

What we offer you:

Competitive Pay

Medical * Dental * Vision * Life * STD Insurances.

401K retirement plan.

ABOUT ROCKLEDGE HEALTH & REHAB CENTER- Located in Rockledge, FL, we are a skilled nursing and rehabilitation facility that is dedicated to helping our residents maximize their potential and live their lives to the fullest. We offer a modern, comfortable, and secure facility staffed by caring professionals where individuals receive the finest sub-acute medical care, rehabilitation services, and 24-hour skilled nursing care. We are committed to maintaining a facility where compassionate care is provided in an environment of respect and dignity. It is also a great working environment for our staff as we truly value and appreciate each member of our team!

• Coordinate and implement discharge planning for residents transitioning from the facility to home, assisted living, hospitals, or other care settings.

• Conduct discharge assessments and identify residents’ post-discharge needs including medical, social, emotional, and environmental factors.

• Develop individualized discharge plans in collaboration with the interdisciplinary care team.

• Arrange post-discharge services including home health, therapy services, hospice, transportation, durable medical equipment (DME), and community support services.

• Ensure discharge planning begins upon admission and is continuously updated throughout the resident’s stay.

• Provide education and guidance to residents and families regarding discharge options, community resources, and available services.

• Assist residents and families in understanding care needs, insurance coverage, and post-discharge requirements.

• Advocate for residents’ rights, preferences, and psychosocial needs throughout the discharge process.

• Participate in care plan meetings and interdisciplinary team meetings to discuss discharge readiness and barriers.

• Communicate with physicians, nursing staff, therapists, and other healthcare professionals regarding discharge plans.

• Collaborate with hospitals, assisted living facilities, home health agencies, and community providers.

• Ensure compliance with CMS, AHCA, and Florida state regulations related to discharge planning and social services.

• Maintain accurate and timely documentation in the resident’s medical record.

• Follow facility policies regarding resident rights, safe discharge practices, and patient confidentiality (HIPAA).

• Document discharge plans, referrals, follow-up arrangements, and communication with families and providers.

• Track discharge outcomes and identify potential barriers to successful transitions.

• Ensure all required forms, instructions, and referrals are completed prior to discharge.

• Maintain updated knowledge of community resources, including home health agencies, hospice providers, social services, and support programs.

• Establish and maintain relationships with community partners to facilitate smooth transitions of care.

Experience

• Minimum of 1–2 years of experience in discharge planning, nursing, case management, care coordination, or social services within a healthcare setting.

• Experience in a skilled nursing facility, rehabilitation center, hospital, home health, or other post-acute care setting preferred.

• Experience coordinating resident/patient transitions of care, community services, or post-discharge needs preferred.

• Working knowledge of CMS discharge planning requirements and applicable Florida AHCA regulations.

• Understanding of Medicare, Medicaid, managed care, and post-acute care processes.

• Ability to assess and coordinate resident discharge needs in collaboration with the interdisciplinary care team.

• Knowledge of community resources, home health services, durable medical equipment (DME), and other post-discharge support services.

• Strong communication and interpersonal skills when working with residents, families, healthcare providers, and community agencies.

• Ability to manage multiple residents and discharge plans simultaneously, prioritize needs, and meet required timelines.

• Strong clinical or psychosocial judgment appropriate to the individual’s professional background and scope of practice.

• Strong documentation, follow-up, organizational, and problem-solving skills.

• We are an Equal Opportunity Employer https://www.eeoc.gov/poster

• Our facility uses the Florida Background Screening Clearinghouse, 435.12, Florida Statutes. Learn more at https://info.flclearinghouse.com