• Provide professional and friendly proactive care and triage for clinical issues • Embed a family centered care philosophy in care delivery • Demonstrate cultural competence and sensitivity as ability to work with culturally diverse populations • Transition of care for ED/IP/UC care coordination with clinical providers following discharge • Perform a comprehensive assessment of a patient’s clinical, psychosocial, discharge planning and financial needs • Establish rapport and a relationship with the patient and family • Establish, in conjunction with the physician, the patient and interdisciplinary team, a comprehensive plan of care • Communicate plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team • Gather sufficient information from all relevant sources to determine the effectiveness of the plan of care • Document all care management assessments and interventions • Refer to Social Worker or Behavioral Health for complex psychosocial and discharge planning issues