Job Summary: For members of a defined population at Maui Health System, responsible for collaborating with the members of the health care team to facilitate the coordination of appropriate, cost-effective services that are consistent with members plan of care, help achieve his/her optimal level of independence, and enhance quality of life. Essential Responsibilities: • Provides supportive counseling and education to members, families and caregivers, members of the health care team, health plan staff, and the community, including end-of-life issues and Advanced Directives. • Completes comprehensive psychosocial assessment and bereavement evaluations implements a goal directed family care plan, accesses community resources, guides the member through health-related legal processes, consults and supports other health care professionals, provides information & education on services available through MHS Palliative Care continuum, contracted hospice agencies, and available End-of-Life care services. • Provides short term crisis intervention and individual or family counseling when indicated. • Maintain the integrity of Palliative Care referrals [screen, assess and prioritization] and coordinate Palliative Care consultations/sessions while being sensitive to time constraints and resources. • Uses comprehensive psychosocial assessment to evaluate patient goals, social support systems, resources, health status, functional limitations, psychological status, environmental factors, and response to treatment so as to decrease inappropriate utilization of medical services. • Collaborates with the Interdisciplinary Team (IDT) and other members of the health care team, develops and monitors a plan of care designed to promote the members optimal level of functioning and enhance the quality of life. • Identifies, facilitates, and advocates appropriate organizational and community resources to meet the plan of care and ensures that they are implemented for in a cost effective, efficient, and timely manner. • Maintain confidentiality of patient records, information and departmental activities involving patient information. • Analyzes patient and program outcomes to identify improvements in program, quality, and cost effectiveness of Palliative Care activities. • Participates in departmental activities related to education, staff meetings and guidelines/policy development. • Promotes self-awareness and knowledge of current standards of practice in palliative care, and recent innovations in patient care. Maintains current knowledge of laws, regulations, and policies relating to the practice of social work in the local market/local agencies and maintains high social work standards as defined by the NASW Code of Ethics.