Coordinates and implements patient/family care by collaborating with the multidisciplinary team, other payors and partnering with patients/families; establishing a multidisciplinary plan to address identified issues and goals; documenting and communicating in a timely manner; and educating patient/family in order to meet established goals and ensure seamless, coordinated transitions across levels of care. Assures intake evaluation and referral process for prospective patients and families is appropriate by interfacing with medical providers, community resources, public agencies and private clinicians to network in order to facilitate appropriate continuity of patient care and for maintenance of ongoing contracts and relationships.