RN Case Manager

Assessments/Reassessments

Develop a plan of care with members, providers, and community based organizations to ensure the appropriate levels of care

Facilitate communication and collaborative relationships with multidisciplinary healthcare team members

Promote continuity of care, to reduce or eliminate fragmentation, duplication, and gaps in care plan.

Monitor the health status of members, provide education and coordinate community resources.

 Prevent adverse member occurrences when possible and intervene to minimize poor outcomes.

Develop plan to prevent or minimize unplanned care transitions when possible