Description****POSITION IS AS NEEDED / REGISTRY FILLING IN FOR VACATIONS, INCREASED VOLUME, ETC.****Job SummaryCoordinates and facilitates the care of the patient population through effective collaboration and communication with the Interdisciplinary Care Transitions (ICT) team members. Follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with external review agencies. Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall e