The Social Worker LSW reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards. Responsibilities: Psychosocial Assessment and Intervention: Meets directly with patient and family to perform a comprehensive assessment including social, emotional, cultural, mental status, environmental and financial circumstances in conjunction with interdisciplinary assessment of the patient. Recommends a plan of intervention based on patient needs, preference and mutually established goals. Provides psychosocial interventions which include reactions to illness and disability, especially the chronically and terminally ill. Facilitation of informed decision making [including advanced directives] and development of treatment and intervention plans. Adjustment to the hospital setting and compliance with treatment plan. Adjustment and coping with post hospital care needs and linkage to community resources. Gynecological and obstetrical related issues including teen pregnancy, parenting issues, adoption planning, infant developmental problems, drug exposed neonate, fetal death, unplanned pregnancy, pregnancy termination, and other care as needed. Issues related to insurance coverage and payment. Psychiatric symptoms and chemical dependency. Conflict resolution. Family and personal relationship that impact the plan of care and discharge plans. Performs assessments of the physical environment and adequacy of support systems for outpatients to prevent a crisis and/or hospitalization. Provides crisis intervention and/or Protective Services for the elderly without support systems, with impaired mental status and/or victims of suspected abuse/neglect, as well as victims of suspected sexual/physical assault (includes rape and molestation), victims of suspected child abuse or neglect, or victims of domestic violence. Guardianship and/or protective services for patients with significant mental status impairment or unsafe living environment and/or the homeless. Manages Discharge Planning through Placement Coordination, Resource Utilization, and Coordination of Skilled Home Health Care. Actively participates in the stages of discharge planning and ensures that the plan of care is coordinated, facilitated and effectively communicated to the physicians, healthcare team, patient and family. Provide initial screening for all new patients to assure medical necessity, source of funding, and likelihood of needing Social Work and/or discharge planning services. Serves as the point person for the plan of care as it applies to discharge planning needs through facilitation of direct and continuous communication and collaborative decision making, including participation in multidisciplinary rounds and case conferences and other collaborative forums. Coordinates action plans when barriers are present to facilitate resolution. Coordinates discharge planning to ensure a timely discharge through early identification, assessment and intervention for post hospital care needs. Patient assessment, plan coordination and changes to the plan occur, as necessary, to ensure that the patient is discharged when medically ready to other acute hospitals, rehabilitative facilities, extended care facilities, sub-acute care, psychiatric and chemical dependency care, return to home or other living arrangements. Meets directly with patient and family to assess needs, preferences and develop appropriate plan that involves home health care services in collaboration with the physician. Ensures and maintains plan consensus from patient and family, physician and payer. Timely discharge is facilitated through early identification, ongoing assessment and intervention for post hospital care needs. Collaborates and communicates with multidisciplinary team in all phases of discharge planning, ensures and maintains plan consensus from patient and family, physician, and payer as indicated. Proactively identifies and resolves delays and obstacles to discharge. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues and system problems. Seeks consultation from and makes referrals to appropriate disciplines and departments as required to expedite discharge plan. Demonstrates knowledge of community resources and an ability to connect patients and families with these resources Acts as an advocate on behalf of the patient who requires assistance to gain access to needed information, resources, or services. Facilitates review of high risk cases by Office of General Counsel, Risk Management and informs appropriate members of the healthcare team as to interventions needed. Coordinates interventions in collaboration with healthcare team and ensures that interventions are successful. Provides patient and family education that promotes wellness and increases knowledge of the