Attends interdisciplinary rounds and identifies appropriate resources for financial, insurance, transportation, housing, healthcare, mental health, and spiritual services.Leads complex family meetings. Assists patient in the comprehension of complex instructions, resolves conflicts, or facilitates conflict resolution. Provides crisis intervention for patients and family members.Develops behavioral agreements with patient and/or families that address adherence and commitment to treatment plan. Assists with patient fundraising.Interviews and assesses patients, family, caregivers, and/or legal representatives. Performs comprehensive psychosocial assessments for applicable moderate or high-risk patients to assist with care coordination and discharge planning needs.Designs and facilitates support groups and other programs.Consults and collaborates with multidisciplinary transplant providers. Makes appropriate referrals to community agencies, which include but are not limited to: Department of Children & Families (DCF), Adult Protective Services (APS), Social Security Administration (SSA), Center for Medicare Services (CMS), and/or disease-specific resources.May supervise and/or train new staff, students, and interns.Manages cases involving guardianship, abuse/neglect, ethical concerns, and legal involvement. Documents clinical assessments and interventions.