Partners with the multidisciplinary/healthcare team and the Social Services Care Manager to guide/advocate placement to the appropriate Acute rehab, LTACH, SNF, long-term care facility, assisted living facility, or Home Health Care, in-home services, hospice, ancillary OP services and/or DME as clinically appropriate. Identifies high-risk patients through risk stratification tools and ongoing assessments including ED utilization and hospitalizations to address the medical/psychosocial/financial needs of patients and their support systems in both hospital and ambulatory settings.