Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. What you will do: Collaborates with Continuum Care Managers, Case Managers, Care Navigators, Physicians, Nursing, PCP & Collaborates with Continuum Care Managers, Case Managers, Care Navigators, Physicians, Nursing, PCP & multidisciplinary team to support patient populations with chronic illness and multiple co-morbidities.