Completes timely post-discharge calls: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, assess psycho-social status, teach warning signs, review discharge instructions, coordination of care, review goals of care discussion and problem solve barriers. SKILLS AND ABILITIES: Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.