Transitional Care MSW: Discharge Planner & Navigator

Alaska Native Tribal Health Consortium (ANTHC); Anchorage (AK); On-site; USD 60,000 - 90,000; Full time

Benefits offered by this job

Medical Insurance

Dental and Vision Insurance

Retirement Contributions

Paid Time Off

Paid Holidays

Parental Leave

Job summary

Alaska Native Tribal Health Consortium (ANTHC) seeks a social work professional to join the Transitional Care Program. You will identify high‑risk patients, coordinate discharge planning, and collaborate with acute and primary care teams to promote safe transitions and patient wellness.

With a Master’s in Social Work and at least two years of social work experience, you will engage families, coordinate services, and document care plans to improve patient outcomes across care settings.

Qualifications

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

Responsibilities

• Identify care management patients from ED or inpatient services and contact within 24 hours.
• Create and coordinate transitional and discharge plans for chronic, high-risk patients.
• Review medical records to measure progress toward discharge goals.
• Coordinate with multiple care providers and community agencies for smooth transitions.
• Support continuity of care through effective communication and timely interventions.

Skills

Alaska Native culture knowledge

Care coordination

Case management

Interdisciplinary teamwork

Assessment and planning

Patient education

Clinical documentation

Time management

Education

Master’s Degree in Social Work

Tools

Electronic Medical Records

BLS Certification

Job description

Alaska Native Tribal Health Consortium (ANTHC) seeks a social work professional to join the Transitional Care Program. You will identify high‑risk patients, coordinate discharge planning, and collaborate with acute and primary care teams to promote safe transitions and patient wellness.

With a Master’s in Social Work and at least two years of social work experience, you will engage families, coordinate services, and document care plans to improve patient outcomes across care settings.