**Schedule**
PRN, Day Shift
Hours: 8:00am - 4:30pm

**General Summary**

Plans, organizes and implements social work for patients and families. Works in a team model to address patient care needs.

**Essential Functions:**

+ Assesses patients/families in need of psycho-social support throughout the patient's hospitalization and assists patients who require care coordination or community resources referrals. Advocates for patient self-determination and appropriate level of care.
+ Identifies discharge plan by making arrangements for psycho-social, psychological and practical assistance across the continuum of care. Actively engages the patient and family in the assessment, problem solving and referral process including transfer and discharge plans.
+ Notifies patient/clinical team of potential referrals, documents on the medical record in a timely fashion: psycho-social assessments, identified plan, barriers, changes and progress toward plan ...