The Care Coordination Specialist will: Function as a key member of an interdisciplinary, value-based care delivery model, collaborating with patients, nursing, physicians, advanced practitioners, caregivers, and community partners to optimize clinical, quality, and financial outcomes. Perform transition of care management, including timely coordination of services, facilitation of medically necessary referrals, initiating post-acute authorizations if applicable, assisting with transportation needs, and effective linkage to community-based resources to ensure continuum of care.