The Social Worker promotes patient-centered care by evaluating psychosocial needs and coordinating community services for identified patient populations. As part of a multidisciplinary health team, the social worker serves as a liaison between patients, community resources, and post-acute care providers. The role creates and facilitates timely discharge plans, arranges post-acute interventions identified in the plan of care, and supports patient movement across the continuum of care. The position primarily serves Med/Surg units. The social worker collaborates with RN case managers, acute care nurses, physicians, insurance companies, and other staff to identify and address patient needs and barriers to discharge and recovery. The role assesses high-risk patients, develops and updates discharge plans with the RN case manager and clinical team, participates in interdisciplinary care planning, educates patients and caregivers about community resources and post-acute care, coordinates meetings, and supports patients and families as they make difficult decisions consistent with their preferences and values.