RN Care Manager - Ambulatory Services

Coordinate with primary care providers and multidisciplinary teams to facilitate transitional healthcare pathways and prevent readmissions. Assess patient learning needs, develop personalized care plans, and monitor progress toward desired outcomes while removing obstacles to adherence. Educate patients and families on treatments, medications, and continuing care requirements through motivational interviewing and standardized documentation. Identify high-risk patients, navigate referrals, and initiate disease-specific care conferencing to promote self-management and engagement.