Identifies patient and caregiver stressors and strengths to direct interventions throughout the patient's illness, including initiating post-death bereavement support, Demonstrates proficiency in navigating systems, knowledge of community resources, advocacy, individual/group counseling, and rapport building, Understands reimbursement and payer source implications to the plan of care and utilizes resources wisely and effectively. Conducts high-risk admission assessments/follow-ups in hospitals where psychosocial issues are present, including but not limited to patients living alone, inadequate caregiving/decision-maker situations, and significant mental health/substance abuse concerns.