This individual's responsibility will include the following activities: a) complex psycho-social transition planning assessment and reassessment and intervention, b) assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies, c) care coordination, d) implementation or oversight of implementation of the transition plan, e) leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review, f) making appropriate referrals to other departments, g ) communicating with patients and families about the plan of care, h) collaborating with physicians, office staff and ancillary departments, i) assuring patient education is completed to support post-acute needs , j) timely complete and concise documentation in Case Management system, k ) maintenance of accurate patient demographic and insurance information, l) and other duties as assigned. The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient's resources and right to self-determination.