RN Field Case Manager - Telephonic WA State ONLY

Assess the health status of members, establish goals to meet identified health care needs, and plan, implement, and evaluate responses to the plan of care. Collaborate with the multidisciplinary team to address medical, functional, and social barriers, working closely with mental health clinicians to bridge gaps between physical and mental health. Consult with patient's PCP, specialists, or other health care professionals as appropriate, assess patient needs for community resources, and make appropriate referrals for service. Facilitate the patient's transition within and between health care settings in collaboration with the primary care physician and other treating physicians. Completely and accurately document in the patient's electronic medical record, provide counseling and education regarding health maintenance, disease prevention, and condition trajectory, and verify patient understanding of the condition, plan of care, and follow-up recommendations. Actively participate in organizational quality initiatives and collaborative multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery. Maintain credentials essential for practice, including licensure, certification, and CEUs.