Job SummaryWorks with physician and multidisciplinary team members to develop plan of care for each assigned patient from admission through discharge. Ensure patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and evaluations. Assess and respond to patient andfamily needs by coordinating efforts of other team members. Identifies and resolves barriers that hinder effective patient care.Job DutiesWorks in conjunction with physicians, nurses, inter disciplinary team and others to assess, plan and initiate patient plan of care.Facilitates and coordinates details of the actual discharge to appropriate agencies.Facilitates and coordinates an individualized care coordination plan.Serve