Participates in multidisciplinary rounds and initiates timely referrals to other internal healthcare team members (quality improvement, risk manager, social workers, pharmacy, therapy services, etc.) Performs case management activities of assessment, coordination, planning, monitoring, implementation, and evaluation. Ensures patients receive proactive initial assessment of needs, ongoing evaluations, and initiation of discharge planning while facilitating a safe and timely transition from the acute care/hospital setting to an appropriate level of care outside the hospital.