RN Care Manager - Ambulatory Services

Coordinate transitional and chronic care management by identifying eligible patients, assessing needs, and tailoring care plans with the patient's care team. Monitor healthcare pathways to ensure adherence, remove obstacles, and develop personalized short- and long-term plans. Facilitate disease management protocols by communicating with multidisciplinary teams, initiating care conferencing, and assisting with referral navigation. Educate patients and families on treatments, medications, and continuing care while using motivational interviewing to promote engagement and self-management. Identify high-risk patients to prevent readmissions or emergency department visits and document all encounters using standardized processes.