Nurse Care Manager

Conduct patient-centered nursing care in ambulatory settings by evaluating needs, formulating care plans, and revising interventions based on ongoing team collaboration. Provide direct nursing and telephonic services to patients and families, including triaging walk-in/same-day clinic visits and facilitating group nursing visits for chronic illness education. Manage complex cases through chronic disease coordination, critical diagnosis tracking, medication reconciliation, and adherence counseling while ensuring compliance with Joint Commission and PCMH standards. Collaborate with multi-disciplinary and Transition of Care teams to address physical and psychological health aspects, assisting patients in developing self-management goals and accessing appropriate resources.