This job assumes responsibility for bio-psychosocial assessments, patient education, evaluation, referral to appropriate community resources and supportive and crisis interventions. Applies thorough knowledge and use of the company and community based services to coordinate and implement complex discharge plans; collaborates and communicates (verbally and through the maintenance of the medical record) with the multidisciplinary team to (re) evaluate and respond to patient and caregiver needs including, but not limited to, emotional, social, cultural and spiritual needs in relation to adapting to the patient’s medical condition. Additionally, this job may practice clinical social work within the agency only under the supervision of an LCSW employed by the company.