Duties: Coordinate and manage care transitions after discharge from inpatient, emergency, skilled nursing and other settings - outreach within 48 business hours, post-discharge assessment covering medication reconciliation, discharge instructions, barriers to care, symptoms and social determinants; schedule timely PCP and specialist follow-up; complete TCM documentation in EPIC; monitor high-risk patients for complications and readmission risk and escalate via SBAR. Collaborate with physicians, advanced practice providers, nurses, social workers, care managers and the hospital liaison, make referrals to home care, behavioral health, palliative care, pharmacy and community resources, and coach patients and caregivers on diagnoses, medications, treatment plans and self-management.