Job SummaryInteracts with patients, family members, healthcare professionals, and community and state agencies. The Social Worker serves as a liaison between the hospital and community agencies or facilities for the exchange of clinical and referral information. Identifies high risk patients from a psychosocial/financial perspective, assesses the psychological needs of patients and families and provides information, support, counseling, care management, and referrals to appropriate resources. Works collaboratively with the interdisciplinary team to ensure patient needs are met and care delivery is coordinated across the continuum. Resolves psychosocial patient care issues and develops and implements a complex patient transition/discharge plan.Will work with keystone accountable ca