Social Worker PRN Osborn

HonorHealth•Scottsdale, AZ

3d•Onsite

About The Position

The Social Worker is accountable for an assigned caseload and collaborates with patients, caregivers, healthcare providers, and external partners to coordinate care and communicate complex information across the healthcare continuum. The role supports smooth transitions of care and positive patient and family outcomes. The Social Worker works with patients and caregivers early in an inpatient or outpatient episode to prepare for discharge, addressing supportive care, end-of-life decisions, community resources and programs, goal setting, and long-term planning. The role identifies and carries out safe post-acute interventions, assesses readmission risks and outpatient barriers to care, and initiates or assists with advance directives. The position facilitates timely transitions to appropriate levels of care by communicating clinical information and care plans among hospitalists, specialists, primary care providers, and other key providers. It communicates financial obligations and discharge information to patients and families, coordinates handoffs to the next case management team, and provides payers with information needed to obtain service authorization. The Social Worker promotes collaboration among the healthcare team, patients, families, and other significant people; may advocate for patients; and applies relevant laws, regulations, benefits, and practice guidelines to support quality care. The position also participates in developing and maintaining case management metrics, manages its caseload, and performs other related duties as assigned.

Requirements

Master's degree in Social Work.
At least one year as a Licensed Social Worker, or successful completion of a health-related field placement in a master's-level Social Work program.
One of the following required licenses: Licensed Social Worker (LSW), Licensed Clinical Social Worker (LCSW), or Licensed Master Social Worker (LMSW).

Nice To Haves

Two years of case management experience.
Three years as a Licensed Social Worker.
Experience managing behavioral health patients.
Certified Case Manager certification.

Responsibilities

Manage an assigned caseload.
Collaborate with patients and caregivers early in inpatient or outpatient episodes to prepare for discharge, including supportive care, end-of-life decisions, community resources and programs, goal setting, and long-term planning.
Interview patients and identify and carry out safe post-acute interventions, including home visits, behavioral health service coordination, guardianship, repatriation, adoptions, and coordination involving CPS, APS, and ALTAC.
Assess readmission risk and outpatient barriers to care, including home support, medication management, and patient expectations.
Initiate and assist patients with advance directives.
Facilitate timely transitions from acute care to an appropriate level of care by communicating clinical information and care plans among hospitalists, specialists, primary care providers, and other key providers.
Communicate financial obligations and other discharge-plan information to patients, families, and medical powers of attorney.
Ensure an effective transition and final handoff to the next appropriate level-of-acuity case management team.
Communicate information about inpatient stays and discharge plans to payers to obtain service authorization.
Promote collaboration and communication among healthcare team members, patients, clients, families, and significant others to support appropriate integrated care from admission through discharge.
Participate in developing and maintaining case management metrics.
Advocate for patients as needed, facilitate communication, and monitor care using standards of care and evidence-based practice guidelines.
Apply knowledge of relevant laws, regulations, government and insurance benefits, and practice guidelines and standards of practice.
Perform other related duties as assigned or requested.