p>• Manages and provides comprehensive, advanced nursing care, including post-discharge aftercare visits, annual comprehensive assessment visits, palliative care-care management program onboarding, and change in condition assessment visits (including physical examination, comprehensive history, screening for physical and/or psychological conditions, and point of care testing). Urgent interventions (i.e., escalations for the Care Teams, RPM, and the 24/7 Line), pharmacological and non-pharmacological interventions, ordering treatments and DME, preventative health maintenance activities, care management, referrals, discharge planning, counseling, and patient education.