Foster continuity of care and facilitate transitions across inpatient and outpatient settings.Provide patient evaluation, assessment, and implementation of planned interventions via in person care and tele-management.  Provide patient care to heart failure patients through infusion therapy with IV diuresis, electrolyte management, and other urgent treatment needs.  Participate in the tele-management of heart failure patients, including symptom assessment, education and interventions as directed by providers Utilize various resources available within the Ambulatory Care to determine and meet the needs of the patient/family.Foster continuity of care and facilitate transitions across inpatient and outpatient settings.Other Duties a