div class="pf-rwd-jobdetails-detail-row" id="DETAIL_ROW_1">Summary:
Ensures collaboration among multiple parties; the patient, family and the multi-disciplinary team (internal and external stakeholders), which may include the payer in an effort to facilitate and coordinate services specific to the patients' needs during an episode of care and/or post-hospitalization.
· Coordinate of care post-hospitalization may include discussions with primary care physician regarding discharge planning to the acceptable level of care (return to the same facility, no psychosocial issues) and/or refer to the appropriate community resources (WIC, food stamps, HRSA- medical assistance, etc.).