Transitional Care MSW Case Manager I - Palliative Care

Alaska Native Tribal Health Consortium (ANTHC); Anchorage (AK); On-site; USD 80,000 - 110,000; Full time

Benefits offered by this job

Medical Insurance

401(a) Retirement Plan

Paid Time Off

Tuition Discounts

Job summary

Alaska Native Tribal Health Consortium (ANTHC) seeks a Social Worker to lead proactive care planning and transition support across acute and post-acute settings in Alaska. You will collaborate with medical providers, patients, and families to promote wellness and satisfaction through care transitions.

With a Master’s in Social Work and 2+ years of non-supervisory experience, you will drive discharge planning, care coordination, and patient advocacy while navigating diverse communities and tribal

Qualifications

• Master’s Degree in Social Work.
• Two years of non-supervisory experience in social work.
• Current Basic Life Support (BLS) certification.

Responsibilities

• Identify care management patients by accessing ED or inpatient services and establish contact within 24 hours of referral.
• Create and coordinate transitional and discharge plans for chronic, high-risk patients.
• Conduct concurrent medical record reviews to measure progress toward discharge goals.
• Prepare and present cases for discussion at scheduled meetings.
• Coordinate interventions, treatments and procedures to meet patient needs during inpatient care and ensure clear communication among providers.

Skills

Care coordination

Interdisciplinary teamwork

Cultural competency

Patient advocacy

Proactive care planning

Education

Master’s Degree in Social Work

Tools

EHR systems

Job description

The Alaska Native Tribal Health Consortium is a non‑profit Tribal health organization designed to meet the unique health needs of Alaska Native and American Indian people living in Alaska. In partnership with the more than 171,000 Alaska Native and American Indian people that we serve and the Tribal health organizations of the Alaska Tribal Health System, ANTHC provides world‑class health services, which include comprehensive medical services at the Alaska Native Medical Center, wellness programs, disease research and prevention, rural provider training and rural water and sanitation systems construction.

ANTHC is the largest, most comprehensive Tribal health organization in the United States, and Alaska’s second‑largest health employer with more than 3,100 employees offering an array of health services to people around the nation’s largest state.

Our vision: Alaska Native people are the healthiest people in the world.

ANTHC offers a competitive and comprehensive Benefits Package for all Benefit Eligible Employees, which includes:

• Medical Insurance provided through the Federal Employee Health Benefits Program as a Tribal Employee, with over 20 plans and tiers.
• Cost-Share Dental and Vision Insurances
• Discounted Pet Insurance
• Retirement Contributions with Pre‑Tax or Roth options into a 403(b).
• 401(a) ANTHC Retirement Plan: After one year of employment, ANTHC will begin making matching contributions of up to 5% of your eligible pay, based on your own contributions. In addition, you may be eligible for an annual discretionary contribution of up to 3% from the employer.
• Paid Time Off starts immediately, earning up to 6 hours per pay period, with paid time off accruals increasing based on years of service.
• Eleven Paid Holidays
• Paid Parental Leave or miscarriage/stillbirth eligibility after six months of employment
• Basic Short/Long Term Disability premiums, Accidental Death and Dismemberment (AD&D) Insurance, and Basic Life Insurance are covered 100% by ANTHC, with additional options for Short‑Term Disability Buy‑Up Coverage and Voluntary Life for yourself and your family members.
• Flexible Spending Accounts for Healthcare and Dependent Care.
• Ancillary Cash Benefits for accident, hospital indemnity, and critical illness.
• On‑Site Child Care Facility with expert‑designed classrooms for early child development and preschool.
• Employee Assistance Program with support for grief, financial counseling, mental/emotional health, and discounted legal advice.
• Tuition Discounts for you and your eligible dependents at Alaska Pacific University.
• On‑Site Training Courses and Professional Development Opportunities.
• License and certification reimbursements and occupational insurance for medical staff.
• Emergency Travel Assistance
• Education Assistance or Education leave eligibility
• Discount program for travel, gym memberships, amusement parks, and more.

Alaska Native Tribal Health Consortium has a hiring preference for qualified Alaska Native and American Indian applicants pursuant to P.L. 93-638 Indian Self Determination Act.

Position Summary

Under administrative supervision, collaborates with the specialty and acute care team, medical providers, post‑acute care team representative, the patient’s primary care manager, the patient, and the patient’s family to identify and manage proactive care planning and interventions to promote patient wellness and satisfaction during the continuum of care transitions.

Position Responsibilities

• Identifies care management patients by accessing Emergency Department (ED) or inpatient services and establishes personal contact within 24 hours of inpatient or ED referral.
• Creates and coordinates a focused transitional and discharge plan of care for chronic, high‑risk patients based on initial assessment. The assessment is completed in collaboration with the patient, his/her family, direct care providers, primary care manager, post‑acute care providers, community agencies, patient housing providers, and other staff as needed.
• Conducts concurrent medical record review to measure patient progress against goals established for discharge.
• Prepares and presents cases for discussion at scheduled meetings.
• Expedites proper sequencing and scheduling of interventions, treatments, and procedures in accordance with the patient’s need during inpatient care. Manages continuity of effective and timely communication between patient and providers.
• Communicates patient needs with anticipated site coordinator as necessary.
• Reviews transition/discharge plan to ensure the patient and his/her family understand the plan including medications and discharge needs.
• Coordinates with pre‑authorization and financial counselors for acute and post‑acute care as needed.
• Identifies and communicates any problems or issues that affect patient flow, patient satisfaction, patient safety, length of stay management, or outcomes to the department manager and/or appropriate key stakeholders.
• Works with acute and primary care multi‑disciplinary care team to prevent readmissions; identifies and communicates relevant information and facilitates care conference(s) as necessary.
• Displays innovation in problem solving and critical thinking
• Assists leadership in Transitional Care Program development and continuous improvement through measurement and feedback of appropriate outcome based processes and strategies. Actively participates in developing program structure, tools, procedures and communication strategies.
• Recommends changes for process improvement in program policies and operations to meet objectives.
• Performs other duties as assigned or required.

KNOWLEDGE And SKILLS

• Knowledge of Alaska Tribal Health System, ANTHC, and Alaska Native culture(s) and politics.
• Knowledge of multiple care environments – Inpatient (IP), Outpatient (OP), Emergency Department (ED), Skilled Nursing Facility (SNF), and Home.
• Knowledge of the healthcare system and its component parts including sites of care, delivery models, and the roles of various providers and health care professionals.
• Knowledge of the community‑based social service delivery system and its interaction with the health care system.
• Knowledge of working with multi‑cultural populations.
• Skill in assessing and prioritizing multiple tasks, projects, and demands in a high stress environment.
• Skill in managing patient complexity and multiple patients with diverse needs.
• Skill in working on teams to plan and produce defined outcomes within given timelines.
• Skill in thinking broadly and longitudinally, constantly assessing and anticipating the needs of the patient and his/her environment.
• Skill in managing patient complexity and multiple patients with diverse needs.
• Skill in working independently with flexibility and adaptability.
• Strong clinical skills, including an understanding of and ability to implement evidence‑based care.
• Skill in establishing and maintaining effective professional working relations with co‑workers, providers, and representatives of other health care organizations.
• Skill in ability to collaborate and facilitate relationships and consensus among the patient, family, and multidisciplinary providers from many different disciplines.

MINIMUM EDUCATION QUALIFICATION

Master’s Degree in Social Work.

Minimum Experience Qualification

Non-supervisory – Two (2) years of experience in social work.

MINIMUM CERTIFICATION QUALIFICATION

Current Basic Life Support (BLS) card.

Preferred Experience Qualification

• Experience in the Alaska Tribal Health System.
• Experience in an acute care medical setting.

Preferred Certification Qualification

Nationally recognized case management certification is preferred.