Performs in accordance with system-wide competencies/behaviors. Performs other duties as assigned. Advocate on behalf of patient/family/caregivers for services access and for the protection of the patient's health, well-being, safety, and rights. Maintain clinical knowledge of and ensures compliance with regulatory requirements. Complete detailed assessment of every patient in order to establish an understanding of medical and social factors, determine patient's capacity for self-care, identify support systems, outline barriers to discharge, and determine the likeliness of requiring post-hospital services and the availability of such services. Engage in clear communication with the patient/member/caregivers as well as the interdisciplinary care team in order to develop discharge plans. Serve as a liaison between the patient and the care team. Actively collaborate with the attending practitioner, caregivers, and other members of the multidisciplinary team to coordinate an individualized plan of care. Facilitate teams to develop and execute safe and efficient discharges. Maintain knowledge about area resources and their capabilities and capacities as well as various types of service providers available. Ensure appropriate arrangements for post-hospital care will be made before discharge and work to avoid unnecessary delays in discharge. Integrate patients' goals, the health care team's assessment, risks, and available resources in order to develop and coordinate a successful transition plan. Take patient/family/caregiver level of health literacy into consideration. Evaluate patient/family/caregiver level of understanding and engagement with the progress toward goals and incorporate findings into the plan of care. Evaluate the potential impact of social determinants of health that may elevate the risk of a poor transition. Recognize and demonstrate shared accountability in the development of a discharge plan with the patient/member/caregiver as well as with team members to ensure optimal outcomes. Serve as a contact between hospitals and post-hospital care facilities as well as the physicians who provide care in either or both of these settings. Discharge Planning Experience: Coordination of a patient's clinical care needs from either an inpatient hospitalization to outpatient; from a post-discharge facility to a home or assisted living facility; and/or coordination of resources to assist patients from an outpatient MD office. Includes, but is not limited to, insurance authorizations ( medication, transportation, alternate level of care), coordination of care to alternate levels of care ( skilled nursing homes, Inpatient rehab, home, including transportation), initiating and organizing hemodialysis, coordinating inpatient hospice, home hospice or skilled nursing with hospice; and obtaining information and connecting patients to appropriate outpatient regional resources. Nurse Track: Diploma or Associate's Degree. Social Worker. Track: Bachelor's degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of those being served required. No license required. Licensure, Certifications, and Clearances: Nurse track: RN License required. Social Worker. Track: No license is required.