• Manage patients through transitions of care, either face to face in the facility or telephonically, within a defined geographical area and care setting. • Advocate for the patient throughout the care continuum to ensure access to resources and resolution to all barriers to care. • Establish relationships and ensure patient/family are informed of patient condition, plan of care and discharge plan, all discharge instructions, medication reconciliation; rationale of Utilization Management determinations and any financial information associated with such, potential for LTC transition (if applicable) and importance of timely PCP follow-up following discharge. • Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality patient care. • Maintain real-time and accurate records of patient status through care transitions within Oak Street's internal inpatient platform. • Adhere to CMS, state specific and NCQA compliance criteria as related to Transitions of Care. • Coordinate with the Utilization Management team to review medical and payer records to ensure appropriate length of stay and identify any barriers to discharge. • Participate in regular inpatient and post-acute rounding calls with Care Navigation and Utilization Management teams to help determine patient status and appropriate discharge plan. • Assist Utilization Management team with access to external medical record information (if available) when needed to make appropriate determinations. • Collaborate with other transitions team members (e.g., Transitional Care Managers - RN and Transitional Care Coordinators) to ensure safe discharge and timely follow up. • Communicate and coordinate with internal stakeholders to identify and address patient needs (e.g., care team, social work, behavioral health, utilization management, Hard-to-Reach, Central Telehealth, etc.). • Participate in regular meetings with Oak Street Health regional leaders to coordinate program implementation and ongoing management. • Engage directly with inpatient physicians, case managers, medical directors, social workers, and SNFists (where applicable) to facilitate safe and timely discharge, appropriate follow-up care, and next steps. • Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming. • Follow program procedures for documenting and tracking transitions interventions. • Adhere to CMS, state, and NCQA compliance criteria as related to Transitions of Care. • Other duties, as assigned.