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 adherence, remove obstacles, and develop self-management goals while reducing readmissions and high-cost utilization. Orient patients and families on treatments, medications, and continuing care; intervene to correct deviations in the expected plan of care. Navigate external provider networks including Health Plans and FQHCs to expedite tests and consults. Assess patient activation and readiness for change, utilizing motivational interviewing to promote engagement. Document all encounters using standardized processes. Requires a BSN, one to three years of inpatient experience, and a current California nursing license. Bilingual Spanish skills preferred.