RN Field Case Manager - Telephonic WA State ONLY

Assess the health status of members within the scope of licensure and establish goals to meet identified health care needs. Plan, implement, and evaluate responses to the plan of care while collaborating with the multidisciplinary team to address medical, functional, and social barriers. Work closely with mental health clinicians to bridge gaps between mental and physical health, consult with PCPs and specialists, and facilitate patient transitions between settings. Assess patient needs for community resources, make referrals, and provide counseling and education regarding health maintenance and disease prevention. Verify patient understanding of the condition and follow-up recommendations, then completely and accurately document all interactions in the electronic medical record. Actively participate in organizational quality initiatives and collaborative team meetings to optimize care delivery.