The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge and prevent avoidable re-admissions. • Complex psycho-social transition planning assessment and reassessment and intervention • Assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies • Care coordination, implementation or oversight of implementation of the transition plan, • leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review • Making appropriate referrals to other departments and communicating with patients and families about the plan of care • Performs related duties as required. Required • Education: Master of Social Work. • Certifications/Registrations/Licenses: • MSW. • Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. • Active license for state(s) covered. Preferred • Experience: 2 years of acute hospital experience. • Certifications/Registrations/Licenses: Accredited Case Manager (ACM) #LI-FG1