Transitional Care Associate

Banner Health•Phoenix, AZ

2d•Onsite

About The Position

The Transitional Care Associate facilitates safe and timely transitions from acute hospital care to other levels of care, including skilled nursing facilities, long-term acute care, inpatient rehabilitation, home infusion therapy, hospice, home care, and community programs. The role arranges discharge services on-site or by telephone and facilitates the discharge plan for services in the designated setting. The associate works with an interdisciplinary healthcare team to coordinate and communicate care arrangements, support patients and families through discharge planning, and transfer relevant patient information to post-acute providers. The position is based at Banner University Medical Center - Phoenix and is full-time, with 40 hours per week, 10-hour shifts across a Sunday–Saturday schedule, and required weekend rotations. Weekend shifts may receive a $3 per hour differential when applicable.

Requirements

Bachelor’s degree in social work or a related field, or licensure as a Licensed Practical Nurse or Licensed Respiratory Therapist.
Knowledge of government and community agencies and resources, including Medicare/Medicaid and long-term care or other applicable resources and services.
Effective communication, customer service, human relations, and time-management skills.
Ability to work flexible hours and rotating weekends.
BLS certification; not required for employees working in the Insurance Division.
For employees working in specified Banner behavioral-health clinical settings serving children: an Arizona Fingerprint Clearance Card at hire, maintained throughout employment, and a signed Arizona Criminal History Affidavit upon hire. For employees working in a behavioral-health clinical setting at BUMCS: an Arizona Fingerprint Clearance Card at hire, maintained throughout employment.

Nice To Haves

Previous experience in a healthcare service setting interacting with patients and families, such as experience in social services, as a licensed practical nurse, or in discharge planning.
Additional related education and/or experience.

Responsibilities

Process and facilitate timely discharge or transfer from hospital care to an identified post-acute setting, and notify care coordination team members when patients or caregivers express concerns or an inability to manage the post-acute plan.
Facilitate and implement care plans and proposed interventions in collaboration with the healthcare team; coordinate, manage, and communicate transition arrangements.
Participate in performance-improvement projects and Banner initiatives, and collect data for project measurement as assigned.
Document interventions and all elements of the discharge plan accurately and promptly in the patient medical record; transfer accurate, pertinent patient information to appropriate post-acute care entities.
Assist and support patients and families in arranging post-acute care, make follow-up calls to patients and providers as indicated, and report concerns to leadership.
Connect patients, caregivers, and families with community resources and communicate anticipated discharge dates and potential care settings.
Maintain knowledge of Medicare, Medicaid, and other program benefits to support transition planning and patient choices.
Implement discharge plans under delegated authority from a provider, licensed MSW, registered nurse, or other licensed healthcare professional; consult a supervisor or manager about unusual situations and communicate discharge plans across the care continuum.