Facilitates coordination and development of comprehensive and individual plan of care in collaboration with patient, family and multidisciplinary team. Initiates Guardianship/APS/CPS referrals when appropriate and communicates with all necessary disciplines and agencies. Acts as Liaison for interdisciplinary communication and coordination of the discharge plan. Utilizes approved departmental communication tools for documentation. Provides individualized care planning consistent with efficient and thorough assessment of patients. Provides follow-up with patient/family during the hospitalization for continuity of care.Acts as a liaison with agency and patient for potential adoption cases. Provides consultation to case managers. Ensures and maintains consensus related to discharge plan from patient, family, physician and payor. Collaborates with nursing staff, case managers, ancillary staff, physicians, facilities and community agencies to identify patient /family educational needs. Communicates with patients/families to ensure understanding of third party payor guidelines.Documents utilization activities and findings based on departmental standards.Facilitates ongoing updates to database to assist with efficient delivery of medical care. BSW from an accredited School of Social Work required, MSW preferred. Acute care hospital experience preferred.