review SNF census, navigate internal systems, gather medical records according to detailed SOP for SOAR SSA, meet with member, interview member and family members to gather pertinent information, communicate with members with language and speech difficulties, navigate SNF environment and social workers for assistance, understand SSA nuances, submit required paperwork and follow up timely according to feedback. Works with leadership to ensure the timely and safe transition of members in the community from various levels of health care services including coordinating care plans with community care coordinators, educating transition enrollees about services, requirements, limitations, and/or exclusions of services as a result of the transition.