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The Case Manager is responsible for contributing to the development of a goal-directed, age-appropriate plan of care through an interdisciplinary team process that is prioritized and based on determined medical diagnosis, patient needs, and expected patient outcomes. The Case Manager collaborates with the interdisciplinary team to develop and document a discharge plan in the most appropriate setting to meet the patient needs while serving as an advocate to patients and families. The Case Manager ensures that activities to facilitate, broker, and coordinate the plan are being implemented, and that the plan is continuously modified based on the patient's changing needs.