Inpatient Transitional Care Associate

Alliance for Care at Home; Tucson (AZ); On-site; USD 52,000 - 76,000; Full time

Benefits offered by this job

Total Rewards

Job summary

Banner Health in Tucson, AZ seeks an Inpatient Transitional Care Associate to support the discharge process on an inpatient behavioral health unit. You will work within a multidisciplinary team to coordinate referrals, care plans, and post-acute services for patients transitioning from acute care to community settings.

The role emphasizes strong communication, care coordination, and collaboration with psychiatric doctors, nurses, and social work.

Qualifications

• Minimum Bachelor’s degree in social work or related field; or equivalent licensure.
• BLs certification may be required depending on role.
• Experience in discharge planning or social services preferred.

Responsibilities

• Facilitate discharge planning and timely transfer from hospital care to post-acute settings.
• Coordinate with care teams and community resources to ensure smooth transitions.
• Document interventions in the patient record and discharge plan.
• Perform follow-up calls to patients and providers as needed; relay concerns to leadership.
• Serve as liaison with home health agencies, nursing homes, hospice, and other post-acute providers.
• Understand and communicate Medicare/Medicaid benefits and options.

Skills

Communication skills

Customer service

Time management

Flexibility

Education

Bachelor’s degree in social work or related degree

Licensed Practical Nurse (LPN)

Licensed Respiratory Therapist (LRT)

Job description

Primary City/State:

Tucson, Arizona

Department Name:

Social Svcs Beh Hlth-Hosp

Work Shift:

Day

Job Category:

Clinical Care

Find your path in health care. We want to change the lives of those in our care – and the people who choose to take on this challenge. If you’re ready to change lives, we want to hear from you.

Banner Health is proud to be recognized on Forbes list of America’s Dream Employers 2027 for the third consecutive year. This recognition highlights our commitment to supporting team members through comprehensive benefits, opportunities for both personal and professional growth, inclusive and empowering work environments, and resources that promote a healthy work-life balance. Banner Health ranked 56 out of the 500 companies made the list.

Banner University Medical Center - South Campus (BUMCS), houses the only Level 1 Academic Medical Center in Tucson meeting the needs of the SMI population. The Behavioral Health Pavilion is also the largest inpatient psychiatric service in Southern Arizona. Our team provides patients a safe, supportive environment that fosters healing and facilitates a return to the highest possible level of independence. Other services include; crisis stabilization, psychiatric assessments, 24-hours psychiatric & nursing care, expressive arts therapy, group therapy, family support therapy, medication management and a separate behavioral health unit within the Emergency Department. You can become an integral member of our patient's team, along with psychiatric doctors, NPs, pharmacists, Registered Nurses and security officers.

As a Inpatient Transitional Care Associate (TCA) on our inpatient behavioral health unit, you will work as part of a multidisciplinary team to support patients throughout their hospitalization and transition back into the community. Key responsibilities include conducting patient intakes, facilitating groups, coordinating referrals for behavioral health and supportive services, and collaborating with various community agencies to ensure continuity of care following discharge. The ideal candidate has previous experience in behavioral health, Title 36, Title 14 through work in social services, in an emergency department, inpatient hospital or outpatient setting. Successful candidates will possess strong communication, care coordination, and teamwork skills, along with a commitment to helping patients access the resources needed to support their recovery and long‑term wellness.

Full-Time Day Shift position: Monday- Friday 8:00am-5:00pm

Your pay and benefits (Total Rewards) are important components of your Journey at Banner Health. Banner Health offers a variety of benefit plans to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life.

Banner - University Medical Center South is a comprehensive academic medical center that includes an Emergency department, a state-designated trauma center and a Behavioral Health Pavilion. We are an Arizona Department of Health Services-accredited Cardiac Receiving Center and a Nurses Improving Care for Health system Elders-designated senior-friendly hospital. The hospital is staffed by physicians who are full‑time faculty of the University of Arizona College of Medicine - Tucson and is managed by Banner Health under an operating agreement with Pima County. Our specialty services include inpatient and outpatient behavioral health, treatment and education for diabetes, innovative geriatrics care and comprehensive orthopedics.

POSITION SUMMARY

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.

MINIMUM QUALIFICATIONS

A Bachelor’s degree in social work or related degree or a Licensed Practice Nurse, or a Licensed Respiratory Therapist required.

Must have knowledge of government/community agencies and resources, such as Medicare/Medicaid, long term care or other applicable resources/services. Must demonstrate effective communication and customer service skills, human relation skills and time management skills. Must be able to work flexible hours and work weekends on rotation. BLS required. (BLS is not required for employees working in the Insurance Division.)

Employees working at Banner Behavioral Health Hospital, BTMC Behavioral or BUMG, BUMCT in a Behavioral Health clinical setting that serves children must possess an Arizona Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment. An Arizona Criminal History Affidavit must be signed upon hire. Employees working at BUMCS in a Behavioral Health clinical setting must possess an Arizona Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment.

PREFERRED QUALIFICATIONS

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.

Additional related education and/or experience preferred.

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