Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing or physician assistants Establishes and maintains effective relationships with patients, care givers, and/or their legal representatives, IDT members, PCPs, other collaborating physicians/providers, and facility staff when applicable Performs an initial comprehensive assessment on all newly enrolled patients and provides ongoing care thereafter. Develops a patient management care plan upon enrollment and updates it as needed when changes in condition warrant or following hospitalization. Meets with patients and/or their legal representatives to review newly developed or modified care plans; involves the PCP or supervising physician in these meetings, when applicable Completes follow-up and post-discharge assessments according to documented standard operating procedure Prescribes appropriate diagnostics and interventions to avoid unnecessary acute admissions Comfortable with basic procedures of nursing care, including IV placement, blood draws, injections, foley catheters, nasal packing, wound care, etc. New hire and annual skills check/training provided Consults with hospital, emergency or post-acute clinical team following notification of patient transfer Educates patients and/or their legal representatives in disease processes affecting patients and ways to manage them effectively, as well as to promote wellness Provides counsel, support and education to staff as appropriate Actively participates in ongoing meetings pertaining to patient care and clinical excellence Implements HEDIS measure campaigns and other quality initiatives to ensure the highest standards of care and to promote the improvement of care management and delivery On-call for caseload during business hours. Participation in clinical after hours on-call program on rotational basis Keeps current on relevant medical and nursing research, technology, and related issues by attending continuing education courses, professional meetings and journal reviews Perform related duties as necessary and other duties as assigned