Promotes the right resources, at the right time and at the right level of care and is responsible for engaging and supporting patients that are in need of care management services; is able to determine, using evidence based guidelines, the correct initial and ongoing level of care for patients and is able to submit appropriate denial review for Medicare, Medicaid and commercial insurers. Develops and coordinates transition plans for patients transitioned to home with home health, community care coordination program, Hospice or Palliative care, home infusion and routine sub-acute and skilled post-acute providers; completes all necessary documentation and necessary handovers.