Key Words: Discharge Planning, Home Health, MCG Guidelines, Social Services, Health Care Navigator, Discharge Planner, Care Manager, Case Manager, LVN, LPN, Licensed Vocational Nurse, Licensed Practical Nurse, Continuity of Care, Transition of Care / Transitional Care, Interdisciplinary Collaboration / Multidisciplinary Team, Comprehensive Patient Assessment, Acuity & Functional Assessment, Medication Reconciliation, Patient & Caregiver Education, Post-Acute & Resource Coordination, Durable Medical Equipment (DME), Home Health Care / Home Care Services, Skilled Nursing Facility (SNF) Placement, Inpatient Rehabilitation / Long-Term Acute Care (LTAC), Community Resource Linkage / Utilization, Transportation & Follow-up Scheduling, Compliance, Payors & Quality Metrics, Medicare / Medicaid Guidelines, Condition of Participation (CoP), Readmission Prevention / Reducing 30-Day Readmissions, Utilization Review (UR) / Case Management, Insurance Verification & Payor Source Management, HIPAA Compliance & Confidentiality. Completes comprehensive assessments of members per regulated timelines and determines who may qualify for care management based on clinical judgment, changes in member health or psychosocial wellness and triggers identified in assessments.