• Provides physicians and members of the interdisciplinary health care team with appropriate and timely biopsychosocial information related to the patient's need for medical care and evaluates the plan of care with changing conditions, additional information or upon request and referral.
• Identifies patient's psychosocial needs in collaboration with the health care team and implements plan of care and appropriate intervention to meet identified needs.
• Reviews medical record, interviews patient and family members or responsible party.
• Discusses case with the multidisciplinary team to develop and implement appropriate interventions.
• Assesses patient and family level of understanding of diagnosis and treatment and determines ability to comply with medical recommendations.
• Provides intervention to maximize compliance with treatment plans.
• Evaluates patient psychosocial, living situation, available supports, and incorporates treatment team recommendations for post discharge care.
• Seeks clarification of information as needed and follows up on outstanding information that impacts final plans and referrals needed.
• Educates patients and families of applicable resources, limitations and relevant financial issues of the services to meet patient needs.
• Coordinates internal and external services to meet the identified needs of patient.
• Communicates to patients, families, and multidisciplinary team in a timely manner when the changes in patient care needs require a change in the expected discharge plan, available community resources, and alternatives that are appropriate to meet the revised plan of care.
• Referrals are completed to appropriate community resources in a timely manner to ensure patient discharges are not delayed due to avoidable actions.
• Assists with completion of resource forms as needed to facilitate timely services to patients.
• Ensures patients are offered choice of vendors in selection of referrals to meet post acute needs.

Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.