The RNCC partners with the Texas Independence Health Plan Institutional Special Needs Plan (ISNP) Nurse Practitioner (Plan NP) to coordinate care for ISNP Beneficiaries (Plan Members), maintaining routine contact with Plan Members, family, and facility staff, and informing Plan NPs and/or facility staff when there are potential medical, emotional, or behavioral changes in a Plan Member's condition. Perform daily rounds to assess changes in Plan Members' conditions, as well as obtain a daily Plan Member census evaluation, documenting and reporting to Plan NPs and RNPs which Plan Members were transferred out of the Facility (to the Emergency Department or for Hospitalization), who has elected Hospice Care, and who has returned from the Hospital in the past 24 hours.