This job functions as the liaison and communicator with the patient, caregivers, healthcare providers, and multi-disciplinary team members as well as post-acute care and third party payers. Discusses alternative care options with patient / caregivers as well as the multi-disciplinary team and assist with discharge planning needs. Facilitates, in collaboration with the multi-disciplinary team, movement along the health care continuum to ensure quality; cost–effective outcomes are achieved.