li>Required Skills: Care coordination, Collaborative care, Conduct initial evaluation, Coordinates with internal and external team members, Develop plan of care to meet patient/caregiver needs, Discharge Summary, Documentation according to plan of care, Documentation of care delivery, plan, goals, etc, Documentation of patient/caregiver teaching/learning, Documentation reflects understanding of coverage criteria, Documents patient response, Documents pertinent information to facilitate care coordination, Educates patient/caregiver to facilitate discharge, Establish and revise goals, Medicaid, Medicare, Participates in care conference activities, Plan of Care, Provide / reinforce individualized patient/caregiver education. Aya Healthcare has an immediate opening for the following position: LMSW (Licensed Masters of Social Worker) in Portland, OR.We’ll work with you to build the healthcare career of your dreams.