Depending on role and clinic location, the RN may provide direct and indirect patient care related to anticoagulation, medication refill, in person, telephone or MyChart triage, Chronic Care Management (CCM), Transitional Care Management (TCM), Behavioral Health Integration (BHI), Principal Care Management (PCM), Advance Care Planning (ACP) facilitation, and other care coordination activities as driven by patient need. The RN collaborates with providers and interdisciplinary team members providing clinical leadership while delivering patient-centered care focused on prevention, health promotion, chronic disease management, care coordination, and population health.