SUMMARY: The individual in this position is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient�s resources and right to self-determination. The individual in this position has overall responsibility to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Conducts complex psycho-social assessment and interventions to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including: