• Performs care management duties to assess, plan and coordinate aspects of medical and supporting services across the continuum of care for post-discharge members • Completes medication review for pre-admission and post-discharge reconciliation • Works with the care management and coordination teams to identify transition support services • Evaluates the needs of the member by completing post discharge assessments for members transitioning from healthcare facilities • Develops a care/service plan and collaborates with discharge planners, providers, specialists, and interdisciplinary teams to support member transition and discharge needs • Facilitates the transition into active care management based on member needs • Provides or facilitates education and resource materials to members, authorized caregivers, and providers to promote wellness activities to improve member overall quality of care • Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulations