Coordinates care and service of selected patients across the health care continuum. Promotes effective utilization of resources and the highest quality of care for optimal clinical and resource outcomes. Ensures appropriate lengths of stay based on medical necessity. Assesses and implements effective discharge planning through identification of appropriate services and facilities across the continuum of care. Assumes a leadership and communication role with the patient/family, interdisciplinary team members, and providers if appropriate services across the continuum. Provides ongoing monitoring and evaluation of the plan across the continuum as appropriate. Education: RN, G