**Job Summary and Responsibilities**

+ Collaborate with Care Teams: Partner with providers, case managers, and social workers to facilitate seamless and timely discharges to home-based services, prioritizing patient-centered care.
+ Guide Patients Through Transitions: Assist patients and families in navigating post-acute care options, addressing barriers, and advocating for home-based services that align with their needs.
+ Safeguard Patient Well-being: Identify opportunities to reduce financial and clinical risks, ensuring patients and families are supported during and after their hospital stay.
+ Advocate During Rounds: Actively participate in multidisciplinary rounds, serving as a patient advocate to ensure efficient and effective continuity of care.
+ Engage Patients Early: Initiate discussions about care destinations and discharge planning upon patient admission, conducting informational visits to promote home health as a preferred option.
+ Prioritize Pati...