Social Worker Shea

HonorHealth•Scottsdale, AZ

3d•Onsite

About The Position

The Social Worker manages an assigned caseload and collaborates with patients, caregivers, healthcare providers, and external partners to coordinate care and share complex information across the health care continuum. The role supports smooth transitions of care, positive patient and family experiences, quality outcomes, and cost-effective care. The Social Worker engages patients and caregivers early in inpatient or outpatient episodes to prepare for discharge, including addressing supportive care, end-of-life decisions, community resources and programs, goal setting, and long-term planning. The role assesses readmission risks and barriers to outpatient care, coordinates safe post-acute interventions, supports advance directives, and facilitates timely transitions to appropriate levels of care. It also coordinates communication among care providers and payers, explains financial obligations and discharge-plan information, supports effective handoffs, contributes to Case Management metrics, and may advocate for patients throughout the care continuum.

Requirements

Master’s degree in Social Work.
One year as a Licensed Social Worker and/or successful completion of a health-related field placement in a Master’s-level Social Work program.
An active license as a 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, caregivers, healthcare providers, and external partners to coordinate care and communicate complex information across the health care continuum.
Engage 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 execute safe post-acute interventions, including pre- and post-discharge home visits, behavioral health service coordination, guardianship, repatriation, adoptions, CPS, APS, and ALTAC.
Assess readmission risk and outpatient barriers to care, including home support, medication management, and expectations.
Initiate and assist patients with advance directives.
Facilitate smooth and timely transitions from acute care to appropriate levels of care by communicating clinical information and care plans among hospitalists, specialists, primary care physicians, and other providers.
Communicate financial obligations and other discharge-plan information to patients, families, and medical powers of attorney.
Ensure effective transition and final handoff to the next appropriate level-of-acuity case management team.
Communicate inpatient-stay and discharge-plan information to payers to obtain service authorization.
Promote collaboration and communication among healthcare team members, patients, clients, families, and significant others to ensure integrated care services are appropriate and beneficial from admission through discharge.
Participate in developing and maintaining Case Management metrics.
Act as a patient advocate as needed, facilitate communication, and monitor care to support quality care using standards of care and evidence-based practice guidelines.
Advocate using knowledge of applicable laws, regulations, government and insurance benefits, practice guidelines, and standards of practice.
Perform other duties as assigned.