Perform comprehensive patient assessments including clinical, psychosocial, environmental, and discharge planning needs

Develop and implement individualized care plans in collaboration with interdisciplinary teams

Coordinate transitions between acute care, rehabilitation, home health, long-term care, and community services

Facilitate discharge planning and identify barriers to safe discharge

Collaborate with physicians, therapists, social workers, and healthcare teams to ensure continuity of care

Advocate for patients and families while navigating complex healthcare systems

Assist with insurance authorizations and utilization review processes

Educate patients and families regarding treatment plans, resources, and post-discharge care

Connect patients with community programs and support servi...