The Social Worker is a professional with education, knowledge, and experience related to the specific area assigned. The role focuses on leadership in the multidisciplinary planning and coordination of the patient's care across the healthcare continuum. The Social Worker organizes the sequence of patient care to attain maximum levels of effectiveness and efficiency to reach desired quality and outcomes. The Social Worker organizes multiple strategies to insure the case of all patients is managed with minimal overlapping roles and processes. The Social Worker participates in a team approach, composed of the physician, nurse, case manager, direct and indirect providers, community resources, and payers. The Social Worker manages home/outpatient services in collaboration with the clinical team and medical provider, provides discharge planning coordination and intervention for high risk and complex patients. The Social Worker strives to promote patient wellness, improved care outcomes, and efficiently utilizes health services among a patient population with complex health needs. Communicates and updates Department Director or Designee on cases that require management level assistance and/or approval as they occur including data collection and reporting. Demonstrates Service Excellence at all times. This position serves patients of all ages and encompasses all other duties as assigned.