Provides department support for the Continuum of Care Team to facilitate discharge planning and ensure appropriate throughput of patients. Works with Case Managers, Transitional Care Coordinator, and Social Workers to ensure discharge plans are communicated to patients and families during hospitalization and post discharge to ensure continuity and identify clinical barriers. Enables a positive patient experience through the discharge process and connection to resources as needed.

Essential Duties:

+ Partners with members of the Continuum of Care team both case managers and social workers (RN Case Manager, SW Case Manager) in an effort to provide patients and family members a smooth, coordinated patient transition from hospital to home and/or the next level of care.

+ Partners with members of the Care Coordination team to ensure appropriate communication occurs at the point of discharge so that the patients’ transition is smooth. Provides timely post-acute con...