Partners with PCPs to ensure care adherence and integration of evidence-based clinical guidelines, preventive guidelines, protocols, and other metrics to develop patient-centered treatment plans; also initiates or adjusts therapies and promotes proven practice as directed by the practitioner and provides appropriate follow up and monitoring as needed. They will interact and collaborate with interdisciplinary care teams, which include physicians, discharge planners, inpatient care managers, referral coordinators, pharmacists, laboratory technologists, social workers, dietitians, educators, nurses, health plan, and other healthcare team members.