Reports to RN Manager Assess the health status of members as within the scope of licensure and with the frequency established in the model of care Establish goals to meet identified health care needs Plan, implement and evaluate responses to the plan of care Work collaboratively the multidisciplinary team to engage resources and strategies to address medical, functional, and social barriers to care  Works closely with mental health clinicians to help bridge the gap between mental and physical health Consult with the patient’s PCP, specialists, or other health care professionals as appropriate Assess patient needs for community resources and make appropriate referrals for service Facilitate the patient’s transition within and between health care settings in collaboration with the primary care physician and other treating physicians Completely and accurately document in patient’s electronic medical record Provide patients and family members with counseling and education regarding health maintenance, disease prevention, condition trajectory and need for follow up as appropriate during each patient visit Verify and document patient and/or family understanding of condition, plan of care and follow up recommendations Actively participate in organizational quality initiatives  Participate in collaborative multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery Maintain credentials essential for practice, to include licensure, certification (if applicable) and CEUs Demonstrate a commitment to the mission, core values and goals of UnitedHealthcare and its healthcare delivery including the ability to integrate values of compassion, integrity, performance, innovation and relationships in the care provided to our members