Summary The Social Worker LMSW Case Management 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 Social Worker LMSW Case Management has overall responsibility for to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Social Worker LMSW Case Management conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge and prevent avoidable readmissions. This Social Worker LMSW Case Management integrates national standards for case management scope of services inc