Please see the full job description for more information Clinical 1. Manage a caseload of complex patients with healthcare needs within a designated population, using specialist knowledge to carry out assessments. 2. Assess; develop; and implement individualised and specialist nursing care programmes in the community. 3. Evaluate treatment interventions for the caseload and modify healthcare plans. Encourage the patient towards self-care and independence, using a health coaching approach and to provide training, education and advice. 4. Work in partnership with other services to and the patient and their family/carer to preventing inappropriate admission to acute hospital settings. 5. Support discharges into the community. 6. Effectively manage and oversee the triage of all referrals to the team. 7. Ensure all aspects of care offered by the team meet the agreed National, Professional and Local standards