Maintains knowledge and reference materials on key resources available to patients and patients’ caregivers across the continuum: -Acts as a knowledge resource for post-acute care resources, included but not limited to, insurance requirements, facility attributes, contact information, etc.-Identifies and refers patients to community services (i.e., transportation, food programs, day programs, and financial programs)-Communicates, consults, and collaborates with a wide range of social agencies, clinics, schools, and courts under the direction of the care team Qualifications . Provides direct administrative support to the care team, patients, and patients’ caregivers:-Support the administrative tasks and communication related to post discharge care (e.g., the 4Next process, faxing to long term care facilities, follow-up appointments, etc.).-Performs administrative tasks to support the ordering of equipment, completion of forms, and medication authorizations.