The Social Worker II facilitates care across the continuum through effective resource coordination, helping patients achieve optimal health, access care, and use resources appropriately while respecting their resources and right to self-determination. The role assesses transition needs, identifies patients at risk for readmission, and conducts complex psychosocial assessments and interventions to support timely throughput, safe discharge, and prevention of avoidable readmissions. The position integrates national case-management standards through transition management, care coordination, compliance with regulatory and accreditation requirements, and education for physicians, patients, families, caregivers, and staff. It also participates in planning the social work component of selected hospital programs and collaborates with community providers to develop educational resources.