RN Care Manager – Cardiac

Conduct comprehensive clinical assessments via phone, develop individualized care plans, and lead Transitional Care Management efforts post-discharge including medication reconciliation. Perform clinical triage to determine escalation needs, assess home safety and social determinants of health barriers, and coordinate urgent appointments with cardiology partners. Serve as the initial point of contact for escalations, provide patient education, and document all encounters per CMS requirements. Review population health dashboards to address care gaps and facilitate interdisciplinary case conferences. Maintain proactive communication with providers while ensuring HIPAA compliance in a secure remote workspace.