Provides initial and ongoing participant assessment, care plan development implementation of care plan for participants living in community, congregate, adult home or skilled nursing facility settings. Responsible for full assessment of participants including obtaining health records, performing physical and mental evaluations, evaluating diagnostic tests, and reporting findings and identifying status changes. Performs complete analysis and assessments of participants including recognizing abnormal findings in testing, exercising clinical judgement and interpreting screenings and other diagnostic tests in accordance with medical standards of care. Monitors ongoing and chronic health problems, anticipating needs and in collaboration with physicians, prescribes and adjusts medication within current practice guidelines and notifies appropriate teams. Appropriately orders consultations with specialists as indicated, outreaches to consultants to request specific goals, reviews recommendations from consultants, takes action as clinically appropriate, and documents timely. Provides ongoing education, counseling and guidance with participants and families including goals of care and participates in family meetings. Monitors care and evaluates effectiveness of individual care plans while making appropriate revisions and notifying family and caregivers Functions as a member of the interdisciplinary team and participates in development of comprehensive plan of care and ongoing monitoring of participants' health status. Participates in clinical administrator on-call rotation. Documents in a timely fashion consistent with CMS standards in ASL EMR. Travels to participant homes and their congregate homes and/or facilities to help bridge care in the community.