Meets directly with, interviews and assesses each member, family or other designated person(s) within 48 hours of admission in order to identify emotional, physical, social, functional and health care needs in order to define and recommend potential discharge plans, manage member and family expectations, identify readmission risk and target interventions to reduce risk for readmission, and identify, adjust and manage barriers to discharge. Apply approved clinical criteria to monitor appropriateness of admissions and continued stays to ensure a clear status determination, assessing appropriateness of level of acuity and care.