• Telephonically assess Medicare, Medicaid, and/or and Group Account members and create actionable and measurable care plans to help guide and track the members' progress toward goals • Use nursing judgment to assess and coordinate care for acute situations (APS, EMS) • Discuss transitions of care to assist with safe discharge to the home and coordinate care for DME, home health, provider appointments, etc. • Guide members and their families toward and facilitate interaction with resources appropriate for the care and wellbeing of members • Assess member’s physical, environmental and psycho-social health issues and work in collaboration with a multi-disciplinary team, such as social workers, dietitians, pharmacists, etc., employing a variety of strategies/techniques to manage appropriately and provide timely intervention