Identifies system, practice and patient issues (including quality of care and quality of life outcomes) and collaborates in their resolution/improvement with appropriate internal (JHS-Risk Management, Medical Records, Patient Finance, Medical Services, etc.) and/or external services or agencies (managed care organizations, AHCA, DCF, CMS, JCAHO, CARF, HRSA, INS, US Armed Forces, etc.). Coordinates, arranges, consults and refers to social worker or other health team members for appropriate services post-discharge as indicated (i.e. ACLF, SNF, REHAB, HHC, DME, community case management, transportation, financial assistance, emotional support, medication, supplies etc.).