The Home Based Primary Care (HBPC)/Care in the Community (CITC) Case Manager (RN) position serves as an advocate and resource in facilitating the care coordination process of community care. Applicant must possess sound clinical judgement, excellent interpersonal and organizational skills. The HBPC/CITC Case Manager (RN) duties include, but are not limited to: Demonstrates leadership in assisting PACT teams to assess and evaluate patients' discharge nursing needs following VA or community hospitalization. Performs eligibility and clinical review of community care consults. Serves as a clinical expert for community care schedulers. Demonstrates understanding of Mission Act and implements according to VA guidelines. Tracks care of Veterans for ongoing care management and discharge from care