Working alongside palliative care and specialty care team members, this position builds trust with patients facing serious, advanced illness; conducts comprehensive assessments in the home, center, or other facilities; monitors proactively for early signs of clinical deterioration; validates findings with the patient’s PCP; coordinates care across specialists and care settings; and escalates to the Physician/NP when a case exceeds nurse-level management. Recognize and act on the two defined escalation paths to the co-located Physician/NP: Door 1, when a PCP, specialist, or the National Medical Director directly requests a physician-level consult; and Door 2, when the Serious Illness Care Guide own escalation criteria are met — a Tier 1 symptom unlikely to resolve at nurse level, a controlled-substance or complex prescribing decision, or a suspected hospice-eligibility determination.