SummaryThe 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