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The RN Care Manager coordinates patient care to support safe, seamless, and timely transitions across the continuum. Using a collaborative process, the RN Care Manager identifies, assesses, plans, implements, and evaluates options and services needed to meet patients’ health and health-related needs, including social determinants that affect overall well-being. The role screens, identifies, and assesses individuals who need active case management services and promotes access to the right resources at the right time and place. The RN Care Manager uses a holistic approach that considers biopsychosocial, functional, cultural, spiritual, and financial factors. The position collaborates with patients, caregivers, and healthcare team members to maximize quality and cost-effective outcomes, monitors and revises care plans as conditions change, maintains timely and clear documentation, and supports care transitions, discharge planning, utilization of resources, and prevention of denials and readmissions.

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