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The Masters Social Worker provides patient care management across the continuum of care and follow-up after discharge for a designated group of patients. The Masters Social Worker is responsible for ongoing assessment of patient needs and coordination of the delivery of patient care through the unit manager, RN Case Manager, and the multi-disciplinary health care team. The Masters Social Worker is accountable to ensure patients meet criteria for admission, continued stay, and discharge. They focus on facilitating the development of discharge plans and the appropriate movement of patients from one level of care to another. In collaboration with the RN Case Managers, they insure a smooth transition to other levels of care. Masters Social Worker function as a liaison with insurers to advocate for patients based on defined needs. There is a significant focus on patient care outcomes and the Masters Social Worker oversees the evaluation of outcomes (treatment and financial outcomes). The practice of the Masters Social Worker is highly collaborative with physicians and other health care team members. They are involved in quality improvement utilizing trended data to focus on issues identified for improvement. Masters Social Worker is a resource to patient/families and members of the multi-disciplinary team. Masters Social Worker are accountable for counseling, education, supporting, and providing information to patients and families consistent with the principles of care and case management. They assist RN Case Managers with the complicated social issues.