Job DescriptionCare Coordination:Screen patients to identify needs and prioritize caseload to identify high risk and rising risk patients.Coordinate with interdisciplinary team to develop, revise, (if necessary due to change in patient progress), and implement appropriate discharge interventions to ensure safety and care coordination.Accepts responsibility for patients' Transitions of Care, coordinating provisions for discharge to including follow-up appointments, home health, community services, transportation, etc., in order to maintain continuity of care on identified high risk patients.Communicate with CRM manager any pertinent findings causing a delay in care coo