Specific functions within this role include:Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in interdisciplinary rounds, and patient/family educationCollaborates 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 needsAssures that the patient is progressing towards their discharge goal and assists to alleviate barriersSeeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge. Actively works to resolve barriers to discharge and engages/escalates barriers to discharge to the appropriate leader for efficient resolutionDocumentation* Initial clinical/psychosocial assessment completed and documented in medical record.*