Partners with the multidisciplinary healthcare team and the Social Services Care Manager to guide/advocate placement to the appropriate Acute rehab, LTACH, SNF, long-term care facility, assisted living facility, or Home Health Care (in-home services), hospice, ancillary OP services, and/or DME as clinically appropriate. Identifies high-risk patients through risk stratification tools and ongoing assessments, including ED utilization and hospitalizations, to address the medical, psychosocial, and financial needs of patients and their support systems in both hospital and ambulatory settings.