Discover Vanderbilt University Medical Center: Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health is committed to an environment where everyone has the chance to thrive and where your uniqueness is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt's mission is to advance health and wellness through preeminent programs in patient care, education, and research. Organization: TMO/UM Team D Job Summary: Collaborates with the health care team to coordinate patient and family interventions across the continuum of care, removing barriers and promoting efficient and effective use of resources. Assists patients and families in establishing patient specific goals, both long term and short term. Facilitates appropriate follow up care and/or refers patients (within the designated patient population) to the appropriate next level or site of care. Serves in an advocacy role on behalf of patients, families, and caregivers to ensure safe healthcare. Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. Assists in the nursing component of developing and meeting key Pillar goals including finance, satisfaction, clinical quality of care, innovation, and growth across the continuum of care.