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 readmissions. This position integrates national standards for case management scope of services including: Transition Management promoting appropriate length of stay, readmission prevention, and patient satisfac