Job Description Summary ‎ Hours & Location: Full Time: Monday-Friday EST Collier county, FL (onsite at NCH North and PRMC Pine Ridge) Coordinates discharge planning and care transition activities for hospitalized patients within the Millennium Physician Group Hospitalist program. Assesses discharge needs, collaborates with physicians, nurses, case managers, patients, families, and community providers, and facilitates appropriate post-acute services to promote safe, timely transitions from the hospital. Supports continuity of care by coordinating services, educating patients and caregivers, addressing barriers to discharge, and ensuring compliance with regulatory and organizational requirements. The Discharge Planner performs professional clinical work under established policies, evidence-based practices, and interdisciplinary care processes. Exercises clinical judgment in coordinating routine and moderately complex discharge plans, escalating higher-risk situations and complex psychosocial or medical issues as appropriate. Work primarily impacts individual patient outcomes, care transitions, and operational efficiency. ‎ 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. Certificates, Licenses, Registrations Registered Nurse, LPN, Social Worker preferred Benefits: 3 weeks PTO & 8 paid holidays Medical, Dental, Vision Employer Paid Basic Life & Short Term Disability coverage (goes into effect after 1 year of full-time employment) 401(k) with match Employee Wellness Other Employee Discount programs like Tickets at Work and cell phone discounts Other benefits: Dependent Care FSA, Voluntary Life, Long Term Disability, Critical Illness, Pet Insurance, and more 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: $55,660.00 to $83,490.00 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. Beware of fraudulent job postings: While Mosaic Health job advertisements may be found on many sites, our current openings page and its associated Workday account are the only places we accept applications for open roles. If you suspect a job post is fraudulent, please let us know at [email protected]. Mosaic Health is a national care delivery platform focused on expanding access to comprehensive primary care for consumers with coverage across Commercial, Individual Exchange, Medicare, and Medicaid health plans. Learn More about Mosaic Health Learn More about Millennium Physician Group Learn More about CareMore Health Learn More about Castlight Health Learn More about Vera Whole Health

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