Job SummaryCollaborates with member, family, healthcare providers and other members of the healthcare team to coordinate services and develop a plan of care. Assesses, plans, implements, monitors and evaluates options and services for members admitted to acute and subacute facilities, receiving home health services or those independent at home.Job DutiesPerforms onsite assessment and telephonic review of admitted Members to determine appropriate management through facts documented in the medical record or recognized from contact with the Member or facility staff.Actively involve with facility staff to insure adequate, appropriate and timely discharge planning.Works with designated transplant vendor to actively manage Members who are identifie