Transitional Care Associate

Banner Health•Tucson, AZ

23h•Onsite

About The Position

The Transitional Care Associate facilitates safe and timely transitions from acute hospital care to post-acute settings and community services, 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 helps implement care plans in coordination with the healthcare team. The associate supports patients and families through discharge planning, communicates anticipated discharge dates and possible care settings, helps arrange appropriate post-acute services, and connects people with community resources. The role also documents discharge interventions and plans in the medical record, transfers relevant information among care providers, performs follow-up calls as indicated, and participates in performance improvement and data collection. Work is performed under delegated authority from a provider, licensed MSW, registered nurse, or other licensed healthcare professional.

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, such as Medicare/Medicaid, 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 is required, except for employees working in the Insurance Division.
For specified Banner behavioral health clinical settings serving children, an Arizona Fingerprint Clearance Card is required at hire and must be maintained during employment; an Arizona Criminal History Affidavit must also be signed upon hire.

Nice To Haves

Previous experience in a healthcare service setting interacting with patients and families, typically through social services, licensed practical nursing, or 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.
Notify care coordination team members when a patient or caregiver expresses or demonstrates difficulty managing the post-acute plan or responsibilities.
Implement care plans and proposed interventions in collaboration with the healthcare team.
Coordinate, manage, and communicate transition-of-care arrangements with healthcare team members.
Participate in performance improvement projects and organizational initiatives, and collect project measurement data as assigned.
Document interventions and discharge plan elements accurately and promptly in the patient medical record.
Transfer accurate and pertinent patient information to appropriate parties across the post-acute care continuum.
Support patients and families in arranging post-acute care, and make follow-up calls to patients and providers as indicated.
Report follow-up concerns to leadership.
Connect patients, caregivers, and families with community resources and discuss anticipated discharge dates and potential care settings.
Maintain knowledge of Medicare, Medicaid, and other program benefits to support transition-of-care planning and choices.
Consult with a supervisor or manager about unusual situations and communicate discharge plans and activities across the care continuum.