Specific functions within this role include: • Transitional care planning, clinical care progression, psychosocial and functional status assessment, attending patient/family care conferences, interdisciplinary rounds, and patient/family education • Collaborates effectively with the utilization review nurse, patient's physicians and the interdisciplinary care team to provide a comprehensive assessment of the patient's medical care needs, psychosocial needs, any social determinants of health needs, goals/outcome attainment and continued care needs • Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers • Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge. The RN Sr will serve as an expert resource and consultant to the other team members in regards to care progression and assisting in planning to effectively meet the patient's needs, manage the length of stay and promote efficient utilization of resources.