ALTCS Care Coordination Social Worker

Pascua Yaqui Tribe; Tucson (AZ); On-site; USD 60,000 - 75,000; Full time

Benefits offered by this job

Paid Time Off: 22 days

15 paid holidays per year

Comprehensive healthcare package

onsite Wellness Center

401(k) with generous match

Profit sharing after 1 year

PSPRS contributions

Job summary

Pascua Yaqui Tribe in Tucson, AZ seeks an experienced Social Worker to provide case management and ALTCS support within the Community Health Nursing Department. The role emphasizes service coordination, documentation, and member advocacy, with no supervisory authority.

Responsibilities include ALTCS applications, PCSPs, home visits, transitions of care, and ongoing assessments. Requires MSW and licensure preferred, with bilingual English/Spanish a plus; driver’s license and AZ clearance card are

Qualifications

• Master’s degree in social work is required.
• Licensure (LMSW/LCSW) preferred depending on assignment.
• Two or more years of medical or community-based social work or case management experience preferred.

Responsibilities

• Assist members and families with ALTCS applications, renewals, and ongoing case management.
• Complete required assessments including UAT, HNT, and related tools within mandated timeframes.
• Develop, implement, and update Person-Centered Service Plans (PCSPs) in coordination with nursing staff.
• Conduct home visits, phone contacts, and community visits for assessment and monitoring.
• Coordinate services prior to hospital discharge and during transitions of care.
• Monitor service delivery, identify gaps, and initiate follow-up or reassessment as required.
• Provide supportive counseling, education, and referrals to address social, financial, and psychosocial needs.
• Advocate for members with insurance programs, transportation services, and community resources.
• Participate in hospital continuity of care meetings and interdisciplinary case conferences.
• Maintain accurate, timely, and compliant documentation in electronic health records.
• Prepare progress notes and reports to support ALTCS requirements and audits.
• Identify, document, and report suspected abuse, neglect, exploitation, or self-neglect in accordance with tribal, state, federal, and organizational requirements.
• Attend required meetings, trainings, and continuing education.
• Perform other duties of similar nature or level as assigned by the Director of Nursing.

Skills

Case management

ALTCS requirements

Interpersonal communication

Confidentiality

Cultural competency (Yaqui culture)

Bilingual English/Spanish

Education

Master’s degree in social work

Tools

Microsoft Word

Outlook

Electronic Health Records (EHR)

Job description

Pascua Yaqui Tribe in Tucson, AZ seeks an experienced Social Worker to provide case management and ALTCS support within the Community Health Nursing Department. The role emphasizes service coordination, documentation, and member advocacy, with no supervisory authority.

Responsibilities include ALTCS applications, PCSPs, home visits, transitions of care, and ongoing assessments. Requires MSW and licensure preferred, with bilingual English/Spanish a plus; driver’s license and AZ clearance card are