Manages and provides the full scope of advanced nursing practice for targeted patient populations, which may include short-term treatment of members at the point of care. Serves as the clinical authority on individualized care teams and leads rounds and interdisciplinary care team meetings. 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). Collaborates with patients, families, primary care physicians and other team members to provide assessment and care planning. Manages and provides clinical services in compliance with standards of Patient-Centered Medical Home standards, meaningful use of medical record data, HEDIS and QARR quality of care measurements. Manages inter-professional team efforts regarding the medical, nursing, therapy and ancillary care provided to patients to ensure quality outcomes are achieved. Participates in on call coverage schedule to ensure 24/7 access to practice clinicians. Assesses, educates, and improves client and caregiver knowledge of chronic disease, self-care management, and identification of changes in health status, including appropriate responses and actions through individualized education and inter-professional interventions. Observes and analyzes team performance patterns related to population under care and assists in developing interventions to improve team performance. Communicates with internal and external care partners regarding the needs of the patient or population to ensure interventions occur in a timely and appropriate manner. Performs procedures as outlined in collaborative practice agreement and as privileged by the Credentialing Committee. Manages quality of medical record documentation and submits billing information in accordance with Professional Corporation policy. Provides care in one or more care settings based on the clinical requirements: virtually, telephonically or travels to patients’ homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options. Performs peer reviews of work performance, including quality of care, clinical documentation, coding and billing practices, communication skills, and population surveillance. May participate in the VNS Health Medical Care at Home Quality and Professional Advisory Committee and any associated workgroups related to development of evidence based clinical models of care, peer education and training, quality improvement, medical record configuration and reporting, maximizing the use of clinical decision support systems. May act as a preceptor for student Nurse Practitioners, providing excellent role modeling of community-based primary care practice. Assumes responsibility for continued professional growth, and maintains professional certification and licensure. Participates in special projects and performs other duties as assigned.