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Description To Heal. To Teach. To Discover. At University Hospitals, this is more than just our mission. These words embody the opportunities available to the many world-class doctors, nurses, health care professionals, and support staff that choose to join UH and Be the Difference. A Brief Overview Under general supervision of the Supervisor, APC Care Management, the APC Administrator and the Ambulatory Site Clinical Lead provider (MD/DO, APRN, PA), perform as a member of the healthcare team to apply the nursing process when making nursing judgments and decisions specific to assessment, planning, implementation/delivery, and evaluation of patient care, and documenting relevant data and care processes. The RN Care Manager will facilitate communication between the patients and their Primary Care Providers. In addition, the RN Care Manager will assist with chronic disease action plans, transitional care management, Advance Directives planning, Annual Wellness Visits, and preventative care utilizing assessment skills both in person and telephonically. This RN position will be a resource for other team members and critical thinking skills are a must What You Will Do Exercise professional nursing judgment appropriate to the level of care needed, and prioritizing patient acuity and workload demands. The RN Care Manager will function with greater autonomy by consistently demonstrating independent clinical decision making abilities. Provide patient care in a manner that demonstrates nursing knowledge and technical competence; recognize significant changes in patient's condition/situation and take appropriate action. Communicate with patient/family including but not limited to relaying physician orders and changes in the plan of care, etc. Assist and provide guidance to other staff members by acting as a nursing resource; appropriately delegate duties in accordance with appropriate rules/regulations and professional standards of nursing practice; promote team collaboration in meeting the needs of the patient/family. Work as a leader in the Advanced Care Model in the ambulatory practice as assigned and work collaboratively with the APC Administrator and Director of APP & UHPS Nursing to drive system wide initiatives and changes RN care management integrated into Primary Care office responsible for managing patient's care across the continuum Analyze sources of data to identify high risk patients and member groups Manage high risk patients including patients with multiple comorbidities or high risk for readmission Develop longitudinal care planning that includes assessment, planning, implementation and monitoring Coordinate continuity of care with patients and families following hospital admission, discharge and ER visits Advocate for patients by assisting in navigation of the health system Communicate to the care team the patient's goals and progress Participate in quality improvement initiatives Participate on data collection team to evaluate health outcomes, trends, utilization, cost reductions, and programmatic evaluation for areas of improvement Provide 1 on 1 office visits for patients to implement care planning Provide health and disease education to patients and families, including group education opportunities Support patients in self-management of their disease and behavior modification interventions As a member of the community care team, identifies appropriate resources including specialists, facilities, and external healthcare organization supports to provide an interdisciplinary approach Collaborate with office staff in the coordination of individual patient care needs Support and facilitate advanced care planning for patients and their families Demonstrate proficiency and act as an expert role model in the performance of patient care Additional Responsibilities Performs other duties as assigned. Complies wit