Duties: Assists the case manager and health care team with the communication and collaboration of the discharge care plan including initiating referrals, i.e. home health, DME, arrange transportation, providing patient choice forms, and making follow up medical appointments Data entry of case related information, submit referrals to facilities and follows-up on bed status and possible bed offers, submit DME necessary referral paperwork and coordinates delivery of equipment upon request of the Case Manager. Assist and work closely with Case Managers, Social Workers, physicians, nurse managers, nursing supervisors, and other members of the health care team to achieve desired outcomes for his/her caseload such as researching patient information, informing patients of their right to choose when referral to SNF, Home Health Care (HHC), etc. and other duties as requested.