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risking risk intervention program Transitional care program Post-Acute Care Team (PACT) readmission reduction program Palliative Care Services (inpatient and outpatient) Hospital based chronic disease management services Post hospital discharge call back/follow up programsDiabetes Education Aligned post-acute partner relationships Physician liaison Other case management programs to be determined based on need Participate with leaders of the hospitals, medical staff, medical group practices, managed care, Post acute care, community stakeholders and clinical areas to achieve optimal clinical and financial outcomes. Directs and coordinates the planning, organizing, prioritizing, implementation and evaluation of the activities and associates engaged in

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