Coordinates the integration of social services/case management functions into the patient care, discharge, and home planning processes; coordinates with external service organizations, agencies and healthcare facilities. • Acts as a liaison between patient/family and healthcare personnel to ensure necessary care is provided. • Effectively and efficiently manages patients throughout the continuum of care. • Performs utilization review to ensure admissions for appropriateness of care and medical necessity. • Coordinates and oversees the care and services of patients to achieve desired clinical and resource outcome. • Coordinates with physicians on patient's progress and discharge needs. • Works with discharge planners and assists in the coordination of support services. • Provides education and support to patients and families related to their medical condition, treatments and the importance of following the continuing treatment plan. • Serves as an advocate for patients in dealing with healthcare providers, insurance plans, and community resources. • Performs all other duties as assigned. • Experience in public health nursing, acute care, case management and/or in-home health care. • Knowledge of disease management strategies. • Knowledge of nursing processes, care management, and continuity of care. • Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; and develops alternative solutions. • Ability to maintain strict protocols of all confidential or sensitive information. • Computer proficiency and working knowledge of Microsoft Office Suite. • Strong verbal, written and interpersonal communication skills.