The nurse translates registry, care-gap, utilization, and Remote Patient Monitoring (RPM) data into clinically appropriate outreach and intervention; develops and maintaining nursing and RPM workflows, coordinates the clinical work of the Case Manager, Community Health Worker (CHW), providers, pharmacy, informatics, and other staff, and helps ensure that patients with complex chronic conditions receive proactive, evidence-based, coordinated care. "This Rural Health Transformation Program is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $206,927,896.80 with 100 percent funded by CMS/HHS.