RN Care Manager - Ambulatory Services

Coordinate transitional and chronic care management by identifying eligible patients, assessing needs, and collaborating with care teams to tailor personalized healthcare pathways. Monitor patient progress toward desired outcomes, remove barriers to adherence, and facilitate scheduling for tests and consults. Develop self-management goals, educate patients and families on treatments and medications, and navigate referrals to prevent readmissions and emergency department visits. Utilize motivational interviewing to promote patient engagement and readiness for change while documenting all encounters using standardized processes.