Performs assessments and formulates discharge/transition plans in collaboration with patient, family and multidisciplinary healthcare team. Provides ongoing monitoring and evaluation of plans to meet the individual needs of patients throughout the care continuum. Works with the multidisciplinary healthcare team to ensure high quality patient care while maintaining fiscal integrity. Assists in resource management through facilitation of care and participation in program planning, data collection and analysis. Provides education to patients/families regarding coverage, care options and community resources. Utilization Care Coordinators master the principles of utilization management to assure the correct level of care throughout the system. High risk care coordinators are responsible for disease-specific population coordination and/or complex care coordination, providing transitional care for patients to appropriate providers, skilled nursing, home health, community support agencies and the patient's home.