Job Summary Manages the care for a specific group of patients. Facilitates the safe movement of patients through the continuum of care, ensures optimal utilization of resources, service delivery and compliance with external review agencies, local, state, and federal requirements. Service includes psychosocial assessments, developing and coordinating discharge plans to ensure continuity of care, providing supportive counseling, and crisis intervention to enhance coping and functioning ability. Assist with overall direction of performance improvement and provides guidance of others. Performs other duties as assigned. Job Responsibilities • Perform a comprehensive psychosocial assessment when triggered to identify the patient's health goals and coordinate services with the RN Case Manager for an effective transition plan. Meets directly with patient/family on an ongoing basis as identified. • Identify the need for patient/family regarding Social/Psychosocial issues that need to be addressed. • Build on the discharge planning assessment in developing, coordinating, implementing and revising a care plan to ensure good transition management and continuity of care (LOS, discharge delays), cost reduction and patient self-management (patient activation). • Collaborates with the physician and all members of the multidisciplinary team to facilitate care and assist in meeting discharge goals. • Completes assigned goals. • Provides direction and guidance to others regarding practice, serves as resource and mentor. Leadership skill demonstrated in decision making and problem solving. Experience: Minimum Required: N3 years of experience as a social worker in medical/clinical setting Preferred: 5 years or greater clinical experience as a social worker in medical/clinical setting. Special Skills: Minimum Required: Excellent interpersonal communication and negotiation skills. Ability to identify and coordinate appropriate resources in the community. Ability to work with people of all social, economic, and cultural backgrounds. Computer Skills. Licensure Description: Minimum Required: LMSW - must be licensed per state requirements Preferred: ACM, CCM