Transitional Care Associate

Banner Health•Tucson, AZ

2d•Onsite

About The Position

The Transitional Care Associate facilitates the safe and timely transition of clients from acute care to alternative levels of care, including skilled nursing facilities, long-term acute care, inpatient rehabilitation, home infusion therapy, hospice, home care, and community programs. The role facilitates discharge plans and arrangements for services in the designated post-acute setting, either on-site or by telephone. The position works collaboratively with patients, families, providers, and interdisciplinary healthcare teams to coordinate discharge plans and communicate relevant information across the post-acute care continuum. It also supports patients and families in identifying appropriate care arrangements and community resources, and follows up with patients and providers when indicated. The role operates under delegated authority and established procedures, documenting interventions and discharge plans accurately and promptly. This is a full-time position at Banner University Medical Center Tucson, with 40 hours per week and 10-hour shifts. Weekend rotations are required, and a $3 per hour weekend shift differential applies when applicable.

Requirements

Bachelor’s degree in social work or a related field, or licensure as a practical nurse or respiratory therapist.
Knowledge of government and community agencies and resources, including Medicare/Medicaid and long-term care or other applicable services.
Effective communication, customer service, human relations, and time-management skills.
Ability to work flexible hours and rotating weekends.
BLS certification, except for employees working in the Insurance Division.
For specified behavioral health clinical settings serving children, an Arizona Fingerprint Clearance Card is required at hire and must be maintained throughout employment; an Arizona Criminal History Affidavit must also be signed upon hire where specified.

Nice To Haves

Previous experience in a healthcare service setting interacting with patients and families, typically gained through social services, licensed practical nursing, or discharge planning work.
Additional related education and/or experience.

Responsibilities

Process and facilitate timely discharge or transfer of clients from hospital care to an identified post-acute setting, and notify care coordination team members of patient or caregiver concerns about managing the post-acute plan.
Facilitate and implement care plans and proposed interventions in collaboration with the healthcare team, coordinating and communicating transition arrangements.
Participate in performance improvement projects and Banner initiatives, and collect project measurement data as assigned.
Document interventions and all elements of the discharge plan accurately and promptly in the patient medical record.
Transfer accurate, pertinent patient information among appropriate entities in the post-acute care continuum.
Assist and support patients and families in arranging the post-acute plan; 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-of-care planning and choices.
Implement discharge plans under delegated authority, consult with a supervisor or manager on unusual situations, and communicate patient discharge plans and activities across the care continuum.