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 This position is an integral member of the care coordination team, working with patients and their families to assure a smooth transition following discharge from the hospital. This position works collaboratively with the various partners, leadership, providers, care coordinators and other health care professionals/agencies to ensure a smooth transition from the hospital to outpatient care that is coordinated across the health care continuum. The Transitional Care Manager collaborates with patients/caregivers early prior to and/or post- discharge. Key areas of focus include: Establish relationship with patient/caregiver Ensure PCP follow up within 7-14 days post discharge Assess readmission risk and barriers to care outpatient including home support, medication management, expectation, etc. Coordinate with hospital case manager regarding discharge plans Provide effective communication of clinical information and plan of care between all care providers Conduct effective post-hospitalization telephonic monitoring, or depending on the tier level of each case and risk for readmission. Review discharge instructions with patient including education required due to new medications/changes to medication regimen, disease specific “red flags” of complications Communicate effectively and professionally using all modalities i.e. technology, written letter, and verbal with both clinicians and patients/caregivers in a way that is both clear and concise. Assesses, determines, and evaluates appropriate disposition and makes independent judgments based on critical thinking skills and expertise. The Transitional Care Manager will facilitate a smooth and timely transition from acute care to home. Participates with a team of registered nurses to answer in-bound nurse help telephone calls from patients/families who have recently discharged home after an inpatient or observation hospital encounter. Obtains & documents information from the electronic medical record to assist in the facilitating and resolution of the patients issues. Collaborates with other members of the hospital or post-acute healthcare team for the timely and effective resolution to the patients issue. Facilitates and 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. Maintains accurate & thorough documentation by means of the approved electronic medical record documentation templates Performs other duties as assigned. Qualifications Education Associate's Degree from an accredited NLN /CCNE institution in nursing or Master's degree in Social Work Required Experience 2 years as a Registered Nurse (RN) or Master’s level Social Worker AND one (1) year as a Case (or Care) Manager or equivalent experience. Required Licenses and Certifications Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure Or Social Worker – LMSW or LSCW Required