Provides psychosocial assessments, crisis intervention, and resource referrals to facilitate discharge plans, adjustment to illness, and complex discharge planning for patients and their families. Formulates discharge plans with patients, families, and the care team based on a needs assessment. Coordinates 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 the patient's hospitalization to ensure appropriate admission status.