Provides discharge/transition assessments, identifying barriers that affect length of stay, identifying barriers to successful clinical outcomes, developing plan of care, facilitates interventions and evaluates adherence to treatment plan through proactive patient engagement for care transitions across the care continuum. Work collaboratively with interdisciplinary team consisting of Social Worker, Resource Navigator, Patient Access, HIM, CDI/UM Specialist, UR Specialist, Corporate staff and others; to meet the overall goals of the organization and metrics specific to the assigned facility.