Additional requirements include completing a post-discharge medication reconciliation, placing appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), providing appropriate disease education, communicating contingency plans for worsening symptoms, and comprehensively assessing a patient's medical conditions. Required skills and experience: At least 3 years of experience in hospital, post-hospital setting, or primary care setting, with clear understanding of common hospital discharge diagnoses, post-discharge needs, and the medical management required to avoid readmissions.