Social Worker - Field-Based

• Conduct in-home or facility-based visits (including SNFs and post-discharge settings) to complete psychosocial assessments, evaluate environmental safety, caregiver capacity, and identify unmet social needs
• Collaborate closely with Care Management, Health Advocates, EMT/paramedic field teams, PCPs, home health agencies, and community partners to ensure continuity of care and address clinical and social complexity
• Assess, plan, and implement individualized care strategies using both internal and community-based resources to support safe discharge, reduce avoidable readmissions, and align with the most appropriate and least restrictive level of care
• Respond to referrals from Care Management or Health Advocates based on risk indicators or unmet needs
• Provide direct case management, psychosocial interventions, and advocacy for members requiring support in areas such as food insecurity, housing instability, transportation, behavioral health, home health, or long-term care placement
• Identify and initiate referrals for financial, psychosocial, community, and state supportive services to promote well-being and independence
• Communicate essential health-related information with all stakeholders to ensure timely, coordinated, and patient-centered services
• Advocate for member autonomy and preference, ensuring that the member’s needs, goals, and rights are respected across care settings
• Utilize approved clinical criteria and understanding of benefits, coverage limitations, and regulatory requirements to support appropriate level-of-care decisions
• Document all assessments, interventions, care plans, and referrals accurately and promptly in care management platforms
• Participate in joint field visits with RNs or other team members as clinically indicated, following established protocols

• Working knowledge of health care delivery systems
• Working knowledge of PC applications including MS Office Suite including other supportive technology
• Ability to use written and oral communication skills
• Ability to read and interpret data
• Skill in writing clear, grammatically correct, easy to use instructional documentation
• Be accountable in identifying learning needs, setting goals and seeking educational opportunities
• Ability to analyze problems and formulate appropriate plans, solutions, and courses of action
• Knowledge of age specific communication needs with the ability to listen actively and respond to internal and external customers in a timely, competent manner both verbally and nonverbally
• Ability to work with frequent interruptions
• Ability to establish and maintain cooperative working relationships with individuals at all levels of the organization and affiliates
• Ability to maintain confidentiality of patient and all related entity business matters of the organization and its partners
• Ability to manage detail and work with accuracy
• Ability to recognize and act appropriately in situations where patient care needs exceed scope of practice
• Skill in working with a team and the ability to collaborate on projects with colleagues
• Skill in working effectively under deadlines and changing priorities

• Promote a positive and productive work environment by acting maturely and responsibly, satisfactorily performing job responsibilities and conducting self in a professional, courteous and respectful manner during all interactions. Must hold relationships to a high standard- respectful approach to all people and interactions, listen to understand, take emotional accountability and exemplify balance of self with all interactions, be receptive to feedback and opportunities keeping an open mind towards growth
• Integrate Lean principles, practices and tools to improve operational efficiency, reduce costs and increase customer satisfaction
• Follow written and oral instructions and completed routine tasks independently
• Completes annual compliance training on HIPAA/Privacy/Confidentiality/Non-Discrimination/Harassment/Integrity Statement and signs Agreements
• Ensures confidentiality of patient information following HIPAA guidelines and company policies
• Attends training to meet the requirements of the job position and as needed or mandated by company policies and regulations
• Has regular and predictable attendance

• Masters degree in Social Work (MSW), Psychology, counseling or equivalent human services graduate degree
• 3+ years of experience in a social care palliative
• Ability to commute within Phoenix, AZ and surrounding cities to sites, clients, or business offices
• Driver’s license and access to reliable transportation

• BLS if working in a clinical setting
• 2+ years of clinical experience preferably in care transitions, case management or community-based health services
• Case management experience
• Experience in managed care
• Bilingual skills (Spanish preferred)

UnitedHealth Group