JOB SUMMARY Accountable for an assigned caseload, works collaboratively with patients, caregivers, healthcare providers, and external partners to ensure that care is coordinated and complex information is provided across the health care continuum, resulting in a smooth transition of care with positive patient/family experience, outcomes, high quality, and cost-effective care. ESSENTIAL FUNCTIONS Collaborates with patients/caregivers early in the inpatient, and/or outpatient episode in preparation for discharge to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needs.