Tasks: Creates and coordinates the overall transition plan of care based on initial assessment and concurrent collaboration with social workers, direct care providers, other hospital departments, external service organizations, agencies and healthcare facilities, community care and navigation services, and the patient and family/caregiver. Manages quality indicators such as avoidable delays, length of stay, resource utilization, patient satisfaction, patient flow, outlier management, and readmissions while suggesting strategies to improve organizational/departmental performance.