You will identify RCA's patients aligned to Evergreen Nephrology early in the hospitalization, engage patients and caregivers at the bedside, collaborate with hospital care teams on discharge readiness, and help close gaps that contribute to an avoidable readmission or prolonged post-acute stay. Collaborate with physicians, case managers, social workers, utilization management teams, discharge planners, and other interdisciplinary team members to support safe transitions home or to post-acute care facility.