Summary 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. The Social Worker has overall responsibility for to assess the patient for transition needs including identifying and assessing patients at risk for readmission. The Social Worker conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge and prevent avoidable readmissions. The Social Worker integrates national standards for case management scope of services including: Transition Management prom