Social Worker- Tempe

HonorHealth•Tempe, AZ

13d•Onsite

About The Position

The Social Worker is accountable for an assigned caseload and works collaboratively with patients, caregivers, healthcare providers, and external partners to coordinate care and communicate complex information across the health care continuum. The role supports smooth transitions of care and positive patient and family experiences, outcomes, quality, and cost-effective care. The position focuses on the Emergency and Inpatient departments at HonorHealth’s Tempe Medical Center. The Social Worker collaborates with patients and caregivers early in an inpatient and/or outpatient episode to prepare for discharge. Work includes supportive care, end-of-life decisions, community resources and programs, goal setting, and long-term planning. The role assesses readmission risk and outpatient barriers to care, assists with advance directives, and coordinates safe post-acute interventions. It facilitates communication and handoffs among care teams, patients, families, payers, and the next appropriate level of care. The Social Worker may also act as a patient advocate and perform other related duties as assigned or requested.

Requirements

Master’s Degree in Social Work is required.
At least 1 year as a Licensed Social Worker, and/or successful completion of a health-related field placement in a Master’s-level Social Work program is required.
Must hold one of the following current licenses: LSW (Licensed Social Worker), LMSW (Licensed Master Social Worker), or LCSW (Licensed Clinical Social Worker).

Nice To Haves

Master’s Degree in Social Work is preferred (also listed as required).
2 years in case management.
3 years as a Licensed Social Worker.
Experience managing behavioral health patients.
Case Management Certification.

Responsibilities

Manage an assigned caseload and coordinate care with patients, caregivers, healthcare providers, and external partners across the health care continuum.
Collaborate with patients and caregivers early in an inpatient and/or outpatient episode 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 timely transitions from acute care to the appropriate level of care by communicating clinical information and plans of care among hospitalists, specialists, primary care providers, and other key providers.
Communicate financial obligations and other discharge-plan information to patients, families, and MPOAs.
Ensure effective transition and final handoff to the next appropriate level-of-acuity case management team.
Communicate information regarding the inpatient stay and discharge plans to payers to obtain authorization for services.
Promote collaborative communication among healthcare team members, patients, families, and significant others to support integrated care from admission through discharge.
Participate in the development and maintenance of Case Management metrics and manage the assigned caseload.
May act as a patient advocate, 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 related duties as assigned or requested.