Required Skills: Advance Directives,Care coordination,Adult protective services,Advance Directives,Benefits Eligibility,Biopsychosocial assessment,Cancer,Case management,Collaborative care,Collect and analyze patient information,Conduct initial evaluation,Coordinate services to home care and equipment following discharge,Coordinates quality care in cost effective manner,Coordinates with internal and external team members,Develop plan of care to meet patient/caregiver needs,Development of problem list,Disease management,Documentation according to plan of care,Documentation of care delivery, plan, goals, etc,Documentation of patient/caregiver teaching/learning,Documentation reflects understanding of coverage criteria,Documents patient response,Documents pertinent information to facilitate care coordination,Establish and revise goals,Food stamps,High risk intervention patient vulnerability or safety risk,Medicaid,Medical Surgical,Medicare,Needs Assessment/ Order DME,Plan of Care,Power of Attorney,Provide / reinforce individualized patient/caregiver education,Refers to other disciplines/resources,Review of Health history,Short Term Acute Care Inpatient Medical Social Worker,Social Security. Travel, per diem, permanent — we have the reach and access to get you the jobs you want, and the expertise to help you realize your long-term goals.