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 that meet individual requirements. Facilitate disease management protocols by communicating with multidisciplinary teams, initiating care conferencing, and overseeing referral navigation. Educate patients and families on treatments, medications, and continuing care while promoting self-management goals and readiness for change. Identify high-risk patients to prevent readmissions and emergency department visits, documenting all encounters using standardized processes.