Assist the provider/team with various care coordination activities in the nursing home Assist the provider/team with benefit determination associated with Medicare part A, part B, and part D benefits Collaborating with the primary APC and nursing facility to identify and respond to patient Change in Condition May assist the provider by completing DSTs, re - assessing the patient, and other activities as delegated by the provider or the CSM Assist the provider/team with therapy coordination for members including possible assessments or follow up on requests and communicate and collaborate with APC May perform interval check in on patient progress with therapy department May participate in facility-based therapy discussion meetings Schedule and participate in family conferences, team meetings, and team case presentations May assist in the coordination of training, tracking and compliance with quality measures Participate in facility partnership or Customer Relationship Management (CRM) meetings under the direction of the APC / CSM May assist in coordinating CRM meetings, and may participate in and contribute to the meetings May assist the team in tracking LearnSource completion for the team members and CSM Assist in creating and conduct in - services for selected audiences Will document information and activities in the EMR May assist Providers in assuring complete and accurate documentation and coding, medication reconciliation, nursing rounds, assessment, and patient documentation Assist the team/providers in prioritizing advance Care Planning and initiating discussions Collaborates with all key stakeholders, providers, nursing homes, PCPs, families, interdisciplinary care teams and any other identified stakeholders Review the chart and enter HEDIS / Quality information into the EMR, communicate gaps to the Provider 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