Coordinates a team approach designed to facilitate the achievement of expected patient outcomes with appropriate transitions to the next level of care; Responsible for length of stay management, regulatory compliance, and attending/participating with interdisciplinary team rounds on assigned unit; Collaborates with community providers to facilitate and coordinate the plan of care for post-hospitalization needs of the patient. Responsible for providing comprehensive assessment, planning, implementation and overall evaluation of individual patient needs; Works collaborate with the Physicians, patient/family, nursing, utilization review and other members of the healthcare team to assure patient management that efficiently and effectively aligns with patient needs using resources to meet quality, clinical and cost effective outcomes.