Responsible for performing patient oriented care management, disease management and care coordination through transitions of care either at an outpatient clinic location and/or telephonically. Utilizes the nursing process to complete assessment and care planning. Collaborates with interdisciplinary care teams to promote quality of life and patient's self management of chr

1. Coordinate and provide care that is safe, timely, effective, efficient, equitable, and client centered 2. Handle case assignments, draft service plans, review case progress and determine case closure 3. Help clients achieve wellness and autonomy 4. Facilitate multiple care aspects (case coordination, information sharing, etc.) 5. Help patients make informed decisions b