Responsibilities:- Assist the care team by providing leadership in supporting and facilitating coordinated care delivery to patients- Proactively identify and eliminate barriers to discharge- Collaborating with the care team to ensure planning for appropriate post-acute care plan and back-up plan.  Specific job functions will vary based on assigned area but would include items such as:- Coordinate services for all patients assigned prioritizing moderate and high risk patients with serious, complex or chronic health problems or with psychosocial issues.- Provide advocacy, information and referral services to patients and families to address their psychosocial needs.- Assists all patients through the healthcare system by acting as a patient advocate and navigator.- Promotes...