Overview Looking to be part of something more meaningful? At HonorHealth, you’ll be part of a team, creating a multi-dimensional care experience for our patients. You’ll have opportunities to make a difference. From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact. HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives. Visit honorhealth.com/benefits to learn more. Join us. Let’s go beyond expectations and transform healthcare together. HonorHealth is one of Arizona’s largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses six acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more. With nearly 14,000 team members, 3,700 affiliated providers and hundreds of volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona. Learn more at HonorHealth.com. Responsibilities Job Summary Accountable for an assigned caseload, works collaboratively with patients, caregivers, healthcare providers, and external partners to ensure that care is coordinated and complex information is provided across the health care continuum, resulting in a smooth transition of care with positive patient/family experience, outcomes, high quality, and cost-effective care. Collaborates with patients/caregivers early in the inpatient, and/or outpatient episode in preparation for discharge to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needs. Interviews, identifies and executes safe post-acute interventions to include pre/post discharge home visits, behavioral health service coordination, guardianship, repatriation, adoptions, CPS, APS, ALTAC, etc. Assesses readmission risk and barriers to care outpatient including home support, medication management, expectation, etc. Initiates and assists patients with advance directives. Facilitates smooth and timely transition from acute care to the appropriate level of care by providing communication of clinical information and plan of care between the hospitalists, specialists and PCP, as well as other key providers. Communicates financial obligations and other key information pertinent to the discharge plan to the patient, family, MPOA, etc. Assures effective transition and final hand-off to the next appropriate level acuity case management team. Communicates key information regarding inpatient stay and discharge plans to payer in order to obtain authorization for services. Promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served from admission through the discharge process. Participates in the development and maintenance of Case Management metrics. Maintains and manages to caseload May act as a patient advocate through the continuum and is available to the physician, patient and family as a resource to facilitate communication and monitors patient care to ensure that the patient receives quality care through the use of standards of care and evidence based practice guidelines. Advocates utilizing knowledge of applicable laws, regulations, government and insurance benefits as well as practice guidelines and standards of practice. Performs other related duties as assigned or requested. Qualifications Education Master's Degree in Social Work Required Experience 1 year as a Licensed Social Worker, and/or successful completion of health related field placement in Master's level Social Work Program. Required Licenses and Certifications Must have one of the following current licensure: LSW (Licensed Social Worker) LMSW (Licensed Master Social Worker) LCSW (Licensed Clinical Social Worker) Required Basic Life Support (BLS) *Some areas may require the BLS or BLS-C Required