Essential Responsibilities and Competencies: Assess, Plan and Facilitate discharge and transitions of care including the following: Review past and present medical records to determine history, admitting diagnosis or procedure, and plan of care compared to previous history and care needs; Gather pertinent information about the patient''s psychosocial, functional and financial situation to identify needs; Meet with patients/caregivers to evaluate clinical, psychosocial, functional and financial status; Communicate with the multidisciplinary team (physicians, nurses, therapists, social workers, chaplain, etc.) as needed to complete assessment; Establish a discharge plan based upon individual patient needs, patient/care-giver preferences, and existing or proposed treatment options in order to support and promote desired clinical, service and financial outcomes in a timely manner; Provide relevant education and information regarding resources to patient/caregiver to facilitate informed decision making and active participation in the plan for transfer/discharge; Determine realistic goals with patient/caregiver regarding available options, empowering them to make choices in their best interest; Identify benefits and coordinate resources based on patient''s needs and preferences; Work with insurance companies and/or public health benefit programs (DSHS, Medicare, Medicaid, County, State) to optimize benefits to patient. OR, for Crisis Counselor role, in lieu of an MSW, a Licensed Mental Health Counselor or Licensed Marriage and Family Therapist credential based on Washington State Department of Health approved masters-level degree credentialing including a minimum of 2 years post-graduate experience working with crisis intervention services including conducting psychiatric assessments; OR, Mental Health Associate Counselor or Marriage and Family Therapist Associate allowed with licensure in the State of Washington (LMHC or LMFT) required within 3 years of employment.