Coordinates and facilitates interdisciplinary provision of comprehensive, patient-centered, quality health care throughout the continuum for patients with acute and chronic health conditions. Fosters achievement of optimal health care outcomes within accepted standards of care. Serves as an expert resource to the healthcare team regarding the continuum of care, efficient use of resources, Best Practice protocols, team-based care, quality indicators and improvements, and regulatory requirements. Ensures a smooth transition of care between multiple health care environments with planned handoffs. Partners with patients and families in identifying health care issues and barriers to self-care in order to set priorities and engage in appropriate interventions. Demonstrates cultural agility and employs health literacy guidelines to provide education regarding self-management strategies. Utilizes rapid quality improvement cycles to continuously monitor, evaluate, measure, and report progress of interventions and outcomes. Paces the case to assure appropriate and fiscally sound care coordination across the continuum.