Medical Social Worker

Job Description

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing whole-person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 6,000 health care providers, including primary and specialty care physicians, hospitals and ancillary providers. We have operated in the Arizona market for more than 13 years, based in Chandler, Arizona, and are an affiliate of Heritage Provider Network.

As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

Under the direction of the Director of Case Management, the Medical Social Worker understands the processes needed to ensure patient specific continuity of care during the transition to alternate levels of care. This individual is knowledgeable of development needs across all age groups including the elderly.

POSITION DUTIES & RESPONSIBILITES

• Partner with Discharge Planners and Care Managers to facilitate safe and effective care transitions tailored to member needs.
• Conduct required home visits to complete psychosocial assessments, safety evaluations, education, and care planning. Home visits are an essential function of this role.
• Provide discharge planning, coordination, referrals, and supportive counseling to members and families.
• Document all encounters, including home visits, telephonic, and virtual contacts, in the EMR timely and accurately.
• Collaborate with interdisciplinary team members (RN, NP, PCP, Behavioral Health, Pharmacy, and community partners) to support whole-person care.
• Support care transitions from hospital, ED, or SNF to home by addressing barriers, scheduling follow-up, and preventing avoidable readmissions.
• Educate members and caregivers on condition management, community resources, and escalation pathways for care.
• Maintain knowledge of and connect members with available community-based resources.
• Follow field safety protocols, PPE standards, and mandatory reporting requirements during all home and community visits.

EDUCATION, TRAINING AND EXPERIENCE