RN Care Manager

RN Care Manager responsible for assessing patients' medical, social, and psychological needs; developing and coordinating individualized care plans with healthcare teams; identifying barriers to care and coordinating services; serving as liaison among patients, families, providers, and community resources; monitoring patient progress through the care continuum; coordinating referrals to specialists and home health; overseeing transitions of care (admissions/discharges); educating patients on diagnoses and self-management; maintaining accurate electronic health records and reporting patient outcomes; participating in quality improvement and adhering to HIPAA and regulatory standards.