Social Worker

Job Description

Job Description

Social Worker - Transitions of Care / Care Management

Location: West Phoenix, AZ
Schedule: Monday-Friday, 8:00 AM-5:00 PM
Work Setting: Mostly Remote | In-person home visits as needed
Employment Type: Full-Time

We are seeking a compassionate and experienced Social Worker (LCSW or LMSW) to join our care management team in West Phoenix. This role has a strong focus on Transitions of Care (TOC) , helping patients safely transition from the hospital back to their homes and communities while reducing avoidable hospital readmissions and overall medical expenses.

The ideal candidate has experience in care management, case management, discharge planning, or transitions of care and is comfortable engaging patients by phone, telehealth, and occasional in-person home visits.

• Manage Transitions of Care (TOC) for patients during and following hospitalization.
• Conduct outreach to hospitalized patients every other day to assess needs and provide support.
• Complete a discharge needs assessment within 24 hours of discharge .
• Identify barriers to successful discharge, including transportation, medications, housing, behavioral health, and social needs.
• Follow up with patients to schedule a provider appointment within 7 days of discharge .
• Provide counseling, case management, education, and appropriate interventions based on patient needs.
• Connect patients with community resources, behavioral health services, and other support programs .
• Coordinate care with providers, health plans, patients, caregivers, and community organizations.
• Monitor patient progress and identify opportunities to prevent avoidable readmissions.
• Conduct in-person home visits as needed to assess safety, resources, and ongoing care needs.
• Provide telehealth support and maintain timely, accurate documentation of patient interactions.
• Advocate for patients and help address social determinants of health that may impact outcomes.
• Work collaboratively with the care management team to improve patient outcomes and reduce healthcare costs.

• Active LCSW or LMSW license required
• 1-2 years minimum of care management experience
• Experience with case management, discharge planning, transitions of care, or healthcare social work preferred
• Strong communication, organization, and patient engagement skills
• Ability to work independently in a primarily remote environment
• Comfortable conducting occasional in-person home visits
• Experience connecting patients with community and behavioral health resources

The ideal candidate is a patient-centered Social Worker who can build trust quickly, identify barriers to care, and coordinate resources across multiple settings. You should be comfortable managing a caseload, making frequent patient outreach calls, collaborating with healthcare providers, and taking initiative to ensure patients have the support they need after leaving the hospital.

• Monday-Friday, 8:00 AM-5:00 PM
• Mostly remote
• West Phoenix service area
• Occasional in-person home visits based on patient needs
• Combination of telephone, telehealth, and in-person patient engagement

This is an opportunity to make a direct impact on patient outcomes by helping individuals successfully transition from hospital care back into the community. Your work will play an important role in preventing avoidable readmissions, improving continuity of care, and connecting patients with the resources they need to remain healthy at home.

For California Applicants:

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).

This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.

Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine.

Our commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?

Company Description

Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine.\r\n\r\nOur commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?