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Banner Health·Tucson, Arizona
Transitional Care Associate
Computed from live listings
Facilitates the safe and timely transition of patients from acute care to post-acute settings or community programs. Manages patient intakes, bed placement, and discharge planning while collaborating with the interdisciplinary healthcare team.
This position facilitates the safe and timely transition of clients from acute care to alternative levels of care such as skilled nursing facility, long-term acute care, inpatient rehabilitation, home infusion therapy, hospice and/or home care or community program. Facilitates discharge plan for the transition of care and services into the designated setting or service. Provides on-site or telephonic discharge arrangements to post-acute and community services.
CORE FUNCTIONS 1. Processes and facilitates the timely discharge/transfer of clients from hospital care to identified post-acute setting. Notifies care coordination team member(s) if patient or caregiver demonstrate or verbalize any inability/concern to be able to manage their post-acute plan or responsibilities.
2. Facilitates/ implements the care plan with proposed interventions in collaboration with healthcare team. Collaborates with all members of the healthcare team to implement, manage and communicate the transition of care arrangements.
3. Participates in performance improvement projects, Banner initiatives and performs data collection for measurement of projects as assigned.
4. Documents all interventions in the patient medical record both timely and accurately including all elements of the discharge plan. Performs transfer of accurate, pertinent patient information between all appropriate entities of the post-acute care continuum.
5. Assist and support patients and families in making appropriate arrangements for the post-acute plan. Performs follow-up calls to patients and providers as indicated and report any concerns to leadership.
6. Serves as an intermediary when providing community resources to patients, caregiver, and families. Discusses with patient, caregiver, and/or family maintaining clear communication regarding anticipated discharge date and potential care settings.
7. Maintains knowledge of Medicare, Medicaid and other program benefits to assist patients with transition of care planning and choices.
8.
Employee has freedom to determine how to best accomplish functions within established procedures and implements the discharge plan under the delegated authority of a provider, licensed MSW, registered nurse or other licensed healthcare professional.
Confers with supervisor/manager on any unusual situations and communicates plans and activities for patient discharge across the care continuum.
Internal customers: Post-acute services team members and all levels of nursing management and staff, medical staff, and all other members of assigned facility interdisciplinary health care team.
External customers: home health agencies, nursing homes, insurance providers, group homes, assisted living facilities, hospice, long-term acute care hospitals, inpatient rehabilitation facilities, volunteer agencies, county/governmental agencies and medical supply companies and others as required.
A Bachelor’s degree in social work or related degree or a Licensed Practice Nurse, or a Licensed Respiratory Therapist required.
Previous experience in health care service setting, interacting with patients and families, usually obtained through work in social services, as a licensed practical nurse or in a discharge planning setting.
Requires a Bachelor’s degree in social work or a related field, or licensure as an LPN or Respiratory Therapist. Must possess knowledge of community resources and government programs like Medicare/Medicaid, along with BLS certification.
Market context
Behavioral health employers in Arizona often look for candidates who can connect directly with clients through lived experience and strong community-based support skills. These roles can be competitive because they may require a high school diploma, a preferred bachelor’s degree, and quick completion of Peer Support Certification, along with a valid Arizona driver’s license and fingerprint clearance. Review the AI-summarized requirements and benefits here to save research time, then confirm your certification timeline and clearance readiness before applying.