Work in collaboration with hospital case managers and or social workers, skilled nursing facilities, Assisted living facilities, Independent Living Facilities, home care agencies, and physicians to provide education to customers, patients and families in coordinating the care of patients moving from one level of care to another to ensure a safe and effective patient’s transition across the post-acute care continuum. Serves as a bridge between the healthcare team and the patient and/or caregivers, as well as helps to reduce facility re-admissions. Provides information and guidance to the patient and/or caregiver resulting in effective care transitions, improved self-management skills and knowledge of their illness and or disease process in addition to supporting enhanced communication between the patient and the healthcare team. Responsible for building and expanding HHCAH relationships as well as identifying opportunities for HHCAH to be a strategic partner generating qualified referra...