JOB SUMMARY Accountable for an assigned caseload, works collaboratively with patients, caregivers, healthcare providers, and external partners to ensure that care is coordinated and complex information is provided across the health care continuum, resulting in a smooth transition of care with positive patient/family ESSENTIAL FUNCTIONS Collaborates with patients/caregivers early in the inpatient, and/or outpatient episode in preparation for discharge to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needs. Promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served from admission through the discharge process.