Social Worker Community Health Nursing

Job Summary

The Social Worker provides case management and social work services within the Community Health Nursing Department, with an emphasis on ALTCS support, service coordination, documentation, and member advocacy. This position is tailored to support nursing-led community health programs and does not include supervisory or program management authority.

• Assist members and families with ALTCS applications, renewals, and ongoing case management.
• Complete required assessments including UAT, HNT, and related tools within mandated time frames.
• Develop, implement, and update Person-Centered Service Plans (PCSPs) in coordination with nursing staff.
• Conduct home visits, phone contacts, and community visits for assessment and monitoring.
• Coordinate services prior to hospital discharge and during transitions of care.
• Monitor service delivery, identify gaps, and initiate follow-up or reassessment as required.
• Provide supportive counseling, education, and referrals to address social, financial, and psychosocial needs.
• Advocate for members with insurance programs, transportation services, and community resources.
• Participate in hospital continuity of care meetings and interdisciplinary case conferences.
• Maintain accurate, timely, and compliant documentation in electronic health records.
• Prepare progress notes and reports to support ALTCS requirements and audits.
• Identify, document, and report suspected abuse, neglect, exploitation, or self-neglect in accordance with tribal, state, federal, and organizational requirements.
• Attend required meetings, trainings, and continuing education.
• Perform other duties of similar nature or level as assigned by the Director of Nursing.

• Knowledge of case management and ALTCS requirements.
• Understanding of medical and psychosocial needs of elderly and vulnerable populations.
• Familiarity with community and tribal resources.
• Ability to assess, document, and coordinate care effectively.
• Strong interpersonal and communication skills.
• Ability to maintain confidentiality and ethical standards.
• Willingness to learn and apply Yaqui culture, customs, and traditions.

Master's degree in social work, minimum of two (2) years of medical or community-based social work or case management experience.

• Licensure (LMSW/LCSW) preferred depending on assignment.
• Experience working with Native American populations preferred.
• Bilingual English/Spanish preferred.

• Must possess and maintain a valid Arizona Driver's License.
• Must have a current Level 1 Arizona Clearance Card or be able to obtain one within ninety (90) days of hire. Failure to maintain a current Level 1 Clearance Card will result in termination from this position.
• Must be available for flexible scheduling, including evenings and weekends as required.
• Proficient in Microsoft Word, Outlook, and electronic health records.