Provides continuity of care by ensuring smooth transitions between care settings. Develops relationships with patients and their multidisciplinary team to facilitate and/or navigate through subsequent treatment and follow-up to reflect continuity of care. Manages high risk, complex patient care with the goal of minimizing readmission. Works closely with physicians to coordinate patient’s care plan communication; works with multidisciplinary team to maintain and implement up-to-date coordinated patient centered care plan; communicates with all members of the healthcare team as patient advocate. Prepares, executes, and reinforces post-discharge care plan. Identifies barriers to care in an effort to elicit changes in processes for patients navigating the continuum of care. Collaborates with leadership to review processes with the goal of improving the clinical experience for referred patients and the referring physician. Adapts behavior to the specific patient population, including but not limited to respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style. Performs other related duties as required. The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time. Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards. This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns. The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.