Specific functions within this role include: Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in interdisciplinary rounds, and patient/family education Collaborates effectively with the utilization review nurse, patient''s physicians and the interdisciplinary care team to provide a comprehensive assessment of the patient''s medical care needs, psychosocial needs, any social determinants of health needs, goals/outcome attainment and continued care needs Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge. Core Responsibilities and Essential Functions: Assessment Based on preliminary screening of patients, initiates assessment of patients chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge.