Overview Summary Manages the care for a specific group of patients; facilitates the safe movement of patients throughout the continuum of care, ensures optimal utilization of resources, service delivery and compliance with external review agencies, local, state, and federal requirements. Collaborates with patients/families and the healthcare team in the transition planning process. Provides psychosocial assessments, education to patients/families to assist in coping with the patient's hospitalization and post acute care needs. Performs other duties as assigned. 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. Requirements, Preferences and Experience Education  Minimum: Masters in Social Work Licensure, Registration, Certification  Preferred: CCM;ACM;LMSW  Minimum: LMSW Special Skills  Minimum: 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. Training  Preferred: 2 years clinical experience as a social worker in medical/clinical setting  Minimum: BSW graduate of an accredited school of social work REQNUMBER: 31928