To perform this job successfully, an individual must be able to perform each essential duty satisfactorily:   - Serve as a single point of contact during initial and follow-up phases of orthopedic care among referring physicians, patients, and caregivers;
- Complete telephonic pre-operative risk assessments and collaborate with physicians and patients to develop an individualized care plan;
- Provide resources and assistance in accessing clinical and supportive care services in the community to better optimize patients for surgery; 
- Gather clinical information from the EMR and telephonic health assessments to determine risk stratification including a comprehensive assessment of the physical, emotional, psychosocial and environmental needs of the patient;
- Track data, conduct analysis and present opportunities for improvement;
- Develop and implement care plans throughout the episode of care;
- Educate patients/caregivers on the process and expectations of healthcare throughout the course of care;
- Participate and assist in assessment, planning and coordination of educational and informational programs for orthopedic population;
- Collaborate as part of a multidisciplinary team to provide patient and family education and communicate with health care providers to coordinate and facilitate services within the episode of care;
- Other responsibilities as needed
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