• Coordinates care services with pod leader to ensure that patients have access to a comprehensive set of services tailored to their needs throughout their healthcare journey • Works collaboratively within the care team to develop and manage personalized care plans, address care gaps, and engage with other resources to ensure access to care • Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly and to ensure that avoidable hospital admissions do not occur • Coordinates and facilitates High Risk Huddles along with ensuring that follow-up actions are completed • Prioritizes patients based on the severity and urgency of their conditions to ensure that the most critical cases receive immediate attention • Reviews medical records to identify gaps in care and coordinate services with the care team to manage these issues • Regularly updates patient care plans • Performs thorough nursing assessments via telephone of patients to maximize or improve current health outcomes • Provides education to patients and/or their caregivers on disease education, medication, health maintenance, and disease prevention to promote self-management and improve health outcomes • Demonstrates strong clinical skills, critical thinking abilities, and effective communication in their interactions with patients, caregivers, providers, fellow care team members, etc. • Documents necessary interactions, assessments, updates, etc. in patients' medical records according to processes and guidelines • Serves as liaison between patients, providers, resources, etc. to ensure seamless care delivery • Facilitates communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care and back to home