Under the supervision of the Nursing Manager, Home Care RN responsibilities includes assessment of participant safety in the community, acute care needs, medication reconciliation, home care needs and to ensure safe transitions of care. In addition, the Home Care RN assists in creating initial and on-going care plans utilizing nursing and home care assessments and attends IDT meetings and Core Team meetings as scheduled. The Home Care RN is a vital member of the IDT. This position collaborates and coordinates care with the Team PCP and social worker on a continuous basis and works with other team members as needed.