Transitional Care Associate

bannerhealth; Phoenix (AZ); On-site; USD 60,000 - 75,000; Full time

Job summary

Banner Estrella Medical Center in Phoenix, AZ is seeking a Transition Care Assistant with a Bachelor’s degree and hospital experience to guide patients and families through the discharge process, participate in multidisciplinary rounds, and communicate discharge plans. You will support post‑acute transitions and coordinate with the care team to ensure smooth care continuity.

Responsibilities include documenting interventions, following post‑acute plans, and assisting patients with navigating

Qualifications

• A Bachelor’s degree in social work or related degree or a Licensed Practical Nurse or a Licensed Respiratory Therapist is required.
• Knowledge of government/community agencies and resources (Medicare/Medicaid) is preferred.
• Effective communication, customer service, time management, and flexibility are essential.
• BLS certification is required (except in certain Insurance Division roles).

Responsibilities

• Facilitates timely discharge/transfer from hospital to post‑acute settings and communicates plans.
• Collaborates with the healthcare team to implement the discharge plan and interventions.
• Participates in performance improvement projects and data collection as assigned.
• Documents interventions in the patient record and coordinates post‑acute care arrangements.
• Supports patients and families with post‑acute planning and community resource referrals.

Skills

Discharge planning

Care coordination

Interdisciplinary collaboration

Communication skills

Education

Bachelor's degree in social work or related field

Licensed Practical Nurse

Licensed Respiratory Therapist

Tools

EMR systems

BLS certification

Job description

Primary City/State: Phoenix, Arizona

Department Name: Case Mgmt-Hosp

Work Shift: Day

Job Category: Clinical Care

A rewarding career that fits your life. Those who have joined the Banner mission come from all walks of life, united by the common goal: Make health care easier, so life can be better. If changing health care for the better sounds like something you want to be part of, apply today.

Are you passionate about making a meaningful difference in patients' lives? We’re seeking a dedicated Transition Care Assistant with a Bachelor's Degree and experience in hospital/healthcare settings or a social work background to join our collaborative interdisciplinary team. In this vital role, you’ll guide patients and families through the discharge process—from reviewing daily holdovers and attending multidisciplinary rounds with physicians, nurses, nutritionists, and pharmacists, to communicating discharge plans and providing crucial support every step of the way. As a valued team member, you’ll experience the rewarding impact of direct patient interaction while building a strong foundation for professional growth in healthcare. If you thrive in fast-paced, engaging environments where your contributions truly matter and collaboration drives success, this is your opportunity to advance your career while making a real difference in patient care!

SCHEDULE

• Full Time/ 40 Hours
• Monday-Friday
• 5 Eight hour shifts
• 7:00am- 4:30pm
• Every 3 weeks weekend rotation (Saturday & Sunday)
• Holiday rotations are required in this role
• Enjoy a flat rate $3/hour weekend shift differential

LOCATION

• Banner Estrella Medical Center

Banner Estrella Medical Center is a 353-bed acute care hospital providing a full range of health care services to the fast growing communities of west Phoenix. Opened in 2005, this is an innovative, fully electronic facility that features electronic medical records, computerized physician order entry, digital radiography, sophisticated ICU monitoring and much more. In fact, we’ve been named one of the “ten most innovative hospitals in the country” by Newsweek Magazine and are recognized by U.S. News and World Report as one of Phoenix’s Best Hospitals. The hospital is also designed to provide a soothing, healing atmosphere for both patients and their family members. We encourage the use of such therapies as pet therapy, aromatherapy, spiritual care and Reiki Therapy.

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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