Job Posting

Transitional Care Coordinator/Discharge Planner/Utilization Review (Exempt)
City, State: John Day, Oregon

Let the adventure begin in Northeastern Oregon surrounded by beautiful mountain ranges, rural ranching community and lots of outdoor activities.


Provide transitional care, discharge planning and utilization review services including psychosocial assessments, brief patient/family counseling, support, resources, education and intervention. Arranges and communicates efficient, timely and cost-effective discharge plans for positive patient outcomes. Participates in performance improvement and continuous quality improvement (CQI) activities.

The TRANSITIONAL CARE COORDINATOR (TCC), along with the Medical Director, provides Transitional Care Program leadership including implementation, care coordination, patient activities, marketing and quality assessment. The TCC is knowledgeable of program components, ensures staff are fully trained, provides program and clinical leadership, oversees and coordinates patient-care from pre-admission through discharge, and is actively involved in all program and quality measures.

The DISCHARGE PLANNER/UTILIZATION REVIEW will plan, organize and evaluate the discharge planning function of the hospital. Works with members of the healthcare team to assure a collaborative approach is maintained in care and treatment of the patient. The Discharge Planner maintains performance improvement activities for the Transitional Care Unit, discharge planning/utilization review and reports activities to the performance improvement committee of the hospital.

Promotes the mission, vision and values of the BMHD.
Knowledgeable of the Transitional Care Program process, clinical and CMS guidelines.
Monitors the program quality measures and supports the development of action plans as needed to improve program processes and outcomes.
Participates in marketing and referral development activities.
Identifies and develops new product lines to meet the needs of the community served.
Develops strong relationships with the other acute care hospital discharge planning staff within the referral area.
Is recognized by the care team, administration and patients and families as essential leader.
Ensures the clinical staff complete education and training and are competent in program clinical skills.
Assess appropriateness of all referrals, engages and educates patient and family on expected discharge plan.
Ensures the Transitional Care program components are in place and functioning properly to include leading Utilization Review (UR) process and interdisciplinary team (IDT).
Ensures the collection pertinent quality metrics into the quality reporting portal.
Communicates with family members and caretakers regarding the needs of the patient and anticipated plans including community resources.
Discharge planning goals are established in coordination with the patient and family/caretakers.
Maintains current knowledge of resources available within the community, maintains supply of resource materials to be distributed to patients for educational purposes.
Follows up on all patient referrals to agencies or other medical facilities.
Accurately determines type of assistance/setting/resources necessary for the patient/family and provides appropriate resources/assistance/list of facilities to monitor potential admission to BMHD swing program.
Effectively and consistently communicates with BMHD personnel and encourages interactive departmental meetings and discussions.
Represents the organization in a positive and professional manner at all times.

Establish & maintain solid work relationships through communication, cooperation, and positive interaction with all employees, staff, patients and physicians.



Master's Degree in Social Work and Board Eligible.
2-5 years of progressive responsibility in discharge planning and demonstrated utilization/case management experience in a recognized program.
Must possess excellent interpersonal skills to effectively represent BMHD in the public realm and be able to interact with fellow team members, nursing/physician/ancillary staff, third-party payors and patients/families in a positive manner.

Management experience,clinical intervention,case management and community outreach services.
Experience as a social worker in a hospital or medical setting.

Basic Life Support (BLS) certified by American Heart Association (AHA). Must obtain within 60 days of hire.

Preferred License/Certification:
Certified Case Manager (CCM) by Commission for Case Manager Certification
Certified Professional Utilization Review (CPUR) or Healthcare Management (CPHM) by McKesson

SUPERVISED BY: Reports to the Chief Nursing Officer (CNO)

Able to communicate effectively in English, both verbally and in writing.
Additional languages preferred.

This job description reflects managements' assignment of essential functions; it does not prescribe the tasks that may be assigned.
Additional Information
Position Type : Full Time

Contact Information
Recruitment Support - General Inquiries Only
Human Resources
170 Ford Street
John Day, OR 97845
Phone: 541-575-1311 #2964
Mental Health and Behavioral Health Counselor, Transitional Care Coordinator, Discharge Planner, Utilization Review, Social Worker, MSW, LCSW, Critical Access Hospital, CAH, Rural Healthcare

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