Demonstrated excellent facilitation skillsProficient in basic word processing skills (Word), internet navigation, and electronic medical recordLicenses and CertificationsLicensed as LMSW by the state(s) in which work is performed (or license within 18 months)Supervision Provided by this PositionThere are no supervisory responsibilities assigned to this job; may delegate to administrative support staff, if applicablePhysical DemandsThe physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion. This role integrates and coordinates various aspects of service delivery, care facilitation, service access, and discharge and post-discharge activitiesCompletes an initial screen of all assigned patients to identify readmission risks, patient strengths and needs related to clinical resource utilization and transition planning; initiates, completes and documents transition planning for patients in assigned caseload.