Job DescriptionJOB SUMMARY: Collaborates with members of the healthcare team, community resources, and with the patient/patient family to promote optimal outcomes for the patient across the continuum of care. Maintains a smaller caseload that requires increased attention and intensive care coordination due to complex social dynamics, legal involvement, and connection with DSS/DDA. Formulates unique solutions to complex discharge planning issues (thinking outside the box). Assists with navigating through barriers that may be preventing the safe disposition of patients. This position is goal oriented with a high level of accountability correlated to the continuum of care, quality of care and patient s