Discharge Planning: Proactively assesses discharge needs from admission, collaborating with the patient, family, social work, case management, and physicians to to line up necessary post-care services and teach them everything they need to know for a smooth and safe transition home. How you'll make an impact in this role: Care Coordination: Acts as the central coordinator, ensuring seamless management and interdisciplinary collaboration (physicians, specialists, therapists, social workers, ancillary staff) for optimal patient outcomes.