Participation in routine primary care team meetings Pro-active management and follow-up (via home visits and by telephone) according to the member’s CarePlan Management and coordination of all transitions of care, including Communicating care plan to providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care) and ensuring providers receive timely clinical data that may impact healthcare treatment decisions Direct caregiver support • Serves as a member advocate and facilitator to resolve issues that may be barriers to care Provide education and coaching to the member, family, and/or caregiver about health status, treatment options, goals of care, and health insurance benefits to assist members in making the most informed decisions and help promote self-management Job Qualifications: Registered Nurse with current, unrestricted state license is required. Regard for confidential data and adherence to corporate compliance policy Demonstrate cultural competency and sensitivity Demonstrate the ability to work autonomously Working conditions and additional requirements: Ability to travel frequently to member’s homes, hospitals, skilled nursing facilities, PCP office practices and other sites where patients receive care.