**Job Summary and Responsibilities**

+ Completes and documents a discharge planning assessment on those patients identified by the designated screening process, or upon request.Reassess the patient as appropriate and update the plan accordingly.
+ Facilitates the development of a multidisciplinary discharge plan, engaging other relevant health team members, the patient and/or patient representative and post acute care providers in accordance with the patients clinical or psychosocial needs, choices and available resources.
+ Oversees and evaluates the implementation of the discharge plan.
+ Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria.
+ Collaborates with the healthcare team and post-acute service providers to ensure timely and smooth transitions to the most appropriate type and setting of post-acute services based upon patients clin...