Ensure accurate and complete documentation Communicate and collaborate with the interdisciplinary care team Collaborate and communicate with PCC to support APC care and scheduling of member Assist the provider / team with various care coordination activities Assist the provider / team with benefit determination associated with Medicare part A, part B, and part D benefits Collaborating with the primary APC and facility to identify and respond to patient change in condition Assist the provider / team with therapy coordination Participate in facility-based meetings Schedule and participate in family conferences, team meetings, and team case presentations Coordination of training, tracking, and compliance with quality measures Assist in creating and conduct in-services for selected audiences Assist Providers in assuring complete and accurate documentation and coding, medication reconciliation, nursing rounds, assessment, and patient documentation May write verbal orders from Provider in the chart in compliance with the state RN practice laws, and in compliance with individual nursing facility practices Assist in managing members through an acute medical situation or an exacerbation of a chronic condition, including testing, diagnostics, interventions Assist in managing members during a short term sub-acute rehabilitation episode