Promotes patient-centered care by coordinating the plan of care for the patient stay. Manages the length of stay, ensuring appropriate resource management. Develops a safe appropriate discharge plan in collaboration with the multidisciplinary team. Facilitates the progression and transition of care using established criteria. Coordinates activities that promote quality outcomes and patient throughput. Identifies patients at risk for adverse outcomes during transition. Performs comprehensive assessment of psychosocial, medical and discharge needs. Reassesses patient's clinical condition. Documents professional recommendations, discharge plan, care coordination interventions, and case management activities.