This position utilizes advanced critical thinking to develop, implement, and evaluate an individualized plan of care that educates, empowers and optimizes patient outcomes throughout all transitions within the continuum of care. It provides leadership, clinical expertise /integration and functional direction to team members in order to ensure quality and continuity of patient services. Serves as the expert resource within a specialty area and participates in assessing specialty population needs and health outcomes. It facilitates continuity of care using nursing process, interprofessional collaboration, coordination of and access to appropriate health care services and community resources.