**Job Description:**

Responsible for assessment, care coordination, discharge planning, and post-acute referrals for patients with complex medical and/or social determinants of health needs in the acute hospital setting.

Job Description

**Essential Functions**

+ Assessment: Identifies patients using screening criteria and conduct comprehensive evaluations.
+ Care Planning: Develops, adjusts, and coordinates care plans to address medical and social needs.
+ Patient Support: Guides self-management using motivational interviewing and coaching.
+ Education & Advocacy: Provides education to healthcare teams and patients, advocate for patient rights, and support self-care.
+ Collaboration: Works with multidisciplinary teams to ensure timely, high-quality care.
+ Process Improvement: Leads initiatives to enhance care transitions and policy adherence.
+ Advanced Care Planning: Provides Goals of Care education for informed decision-making.