DESCRIPTION: Provides direct clinical social work services to patients and their families in an interdisciplinary team approach. Responsibilities include but are not limited to: Completing initial psycho-social assessments on assigned patients, providing psychotherapeutic counseling with individuals, family or groups as needed, giving clinical consultations as needed, providing patient centered advocacy, collaborating with interdisciplinary team, managing complex discharge plans, building and maintaining relationships with internal/external resources, making referrals to community agencies and entitlement programs and continuing ongoing education. Ensure continuity of care of patients with complex post- acute needs and maximizes the patients and families a
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