Works under the supervision of the designated Community Care Team Lead.Serves in an expanded role to collaborate with patients, Primary Care Providers, practice teams, all community agencies, including, but not limited to, behavioral health, housing authorities, Department of Health and Human Services, transportation and home health organizations, and other medical/specialty services to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Assesses patient needs from a strengths based, person in environment manner, to design and implement coordinated intervention plans that monitor and evaluate options and services that aid towards meeting the shared goal of optimizing the patient’s physical and bio-psycho-social-spiritual health status and lowering avoidable costs associated with less than optimal health and/or misuse/overuse of medical/community based services. The Social Worker works collaboratively within Beacon Health’s care coordination program and all care team members to ensure patient needs are met and care delivery is coordinated, and not duplicated, across the healthcare continuum. The expertise of the Social Worker is sought to assess and intervene with bio-psycho-social-spiritual barriers to patient’s engaging with the healthcare system in a manner that promotes optimal health. Utilizes shared decision making models, collaboration, motivational interviewing, and other evidence based patient engagement, activation, and care coordination interventions to encourage positive behavior change in order to assist patients to achieve their highest level of function.