Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations + Providing a comprehensive clinical assessment for the Patient Connect members in a short term stay/transitional setting in collaboration with the case management team to support better care coordination and health outcomes + With a focus on reduction in 30-day hospital readmissions in addition to other primary care responsibilities listed here. + Evaluate plan of care for cost effectiveness while meeting the needs of members, families and providers to decreases high costs, poor outcomes and unnecessary hospitalizations + Program Enhancement Expected Behaviors + Regular and effective communication with internal and external parties including physicians, members, key decision-makers, nursing facilities, CCM staff and other provider groups.