The Post-Acute Transitions Specialist will ensure appropriate patient placement through screenings and assessments in collaboration with SNF Discharge Planners & Inter- Disciplinary Teams, Ambulatory Care Managers, MHP Care Managers, BPCI Transitions Care Coordinator, practice referral coordinators, physicians, and CarePartners Post-Acute service line team members. They will maximize positive financial outcomes for designated patient populations, intervening at key points in the disease process by facilitating appropriate Post-Acute placement, participating in Goals of Care/Advanced Care Planning dialogue and effective transitions to prevent readmissions, and lower total cost of care thru the appropriate utilization of Post-Acute services.