Provides psychosocial assessments, crisis intervention, and resource referrals to facilitate discharge plans and support patients and families with adjustment to illness and complex discharge planning. Formulates discharge plans with patients, families, and the care team based on a needs assessment. Coordinates appropriate referrals to home care agencies, skilled nursing and rehabilitation centers, and community-based programs. Coordinates care authorization with insurers and works with the Utilization Management department on details of a patient’s hospitalization to help ensure appropriate admission status.