Social Worker- Tempe

HonorHealth•Tempe, AZ

11d•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 communicate complex information across the healthcare continuum. The role supports smooth transitions of care, positive patient and family experiences, quality outcomes, and cost-effective care, with a focus on Emergency and Inpatient departments. The Social Worker works with patients and caregivers early in inpatient or outpatient episodes to prepare for discharge, including supportive care, end-of-life decisions, community resources, goal setting, and long-term planning. The role assesses readmission risk and barriers to outpatient care; arranges safe post-acute interventions; assists with advance directives; and coordinates communication and handoffs among care teams, payers, patients, and families. The Social Worker may also advocate for patients and monitor care in accordance with applicable laws, regulations, benefits, standards, and evidence-based practice guidelines. The position is based at Tempe Medical Center and involves variable eight-hour day shifts, weekend rotations, and holidays as needed.

Requirements

Master's degree in Social Work required.
At least 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 required.
Current licensure as one of the following: 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 listed as preferred as well as required.
Two years of case management experience.
Three 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.
Collaborate with patients and caregivers early in inpatient and/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 patient expectations.
Initiate and assist patients with advance directives.
Coordinate 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 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 authorization for services.
Promote collaboration and communication among healthcare team members, patients, families, and significant others to support integrated care from admission through discharge.
Participate in developing and maintaining Case Management metrics.
May act as a patient advocate throughout the continuum, facilitate communication, and monitor 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.