Provides cross coverage for MSO Nurse Case Managers and performs transition of care services, including post-discharge follow-up, medication reconciliation, home visit, and screening members for complex case management criteria. Able to spend 20-40 minutes at a time with patient in the community, including at clinics, specialist offices, hospitals, community-based organizations, or patients home which may be in understaffed/remote areas, in the presence of pets or family members that are tobacco users.