Functioning within Penn Medicine's accountable care and value-based care frameworks, including the Medicare Shared Savings Program (MSSP), this role demonstrates advanced care coordination and transition management expertise to ensure safe, appropriate, and cost-effective discharge planning and post-acute placement. In collaboration with physicians, social workers, utilization management nurses, case managers, and post-acute providers, this role addresses barriers to discharge, aligns care plans with clinical criteria and patient goals, and supports successful outcomes across the continuum of care.