• providing assessments, planning, interventions and follow-up for patients and family members at Shriners Children's across the continuum of care. • coordinating the plan of care to achieve desired outcomes and integrating the work of the health care team. • ensuring the development of a safe and effective plan of care through early identification and assessment of the patient's needs and the resources available. • collaborating by working with patients, families, caregivers, and the health care team locally and within the SHC system to jointly communicate, problem solve, and share accountability for optimal outcomes. • arranging services among community agencies, physicians, patients, family, caregivers, and others involved in the plan of care. • ensuring prudent utilization of all resources by evaluation of the resources available to the patient and balancing cost and quality to ensure optimal clinical and financial outcomes.