ESSENTIAL FUNCTIONS AND RESPONSIBILITIESTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions. * Provide members with transition of care calls to ensure that discharged members receive the necessary services and resources according to transition plan* Conducts a transition discharge assessment onsite and/or telephonically to identify member needs at time of transition to a lower level of care* Independently serves as the clinical liaison with hospital, clinical and administrative staff within our documentation system for discharge planning and/or next site of care needs