RN Field Case Manager - Telephonic WA State ONLY

Assess the health status of members within the scope of licensure, establish goals to meet identified healthcare needs, and plan, implement, and evaluate responses to the plan of care. Collaborate with the multidisciplinary team to engage resources addressing medical, functional, and social barriers, while consulting with the patient's PCP, specialists, or other healthcare professionals as appropriate. Assess patient needs for community resources, facilitate transitions within and between healthcare settings, and provide counseling and education regarding health maintenance and condition trajectory. Completely and accurately document in the patient's electronic medical record 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 and care delivery efficiency.