Job DescriptionThe Nurse Case Manager works in the Comprehensive CARE Center, a transitional clinic that works with patients recently discharged from the hospital. In collaboration with a multidisciplinary team, the nurse case manager is responsible for patients who are identified as high or potential high utilizers of the system to assess and assist in the coordination of patient's care across the continuum. Position functions as a clinician, case manager, and educator to achieve optimal clinical and quality outcomes by effectively managing care and resources to reduce unnecessary utilization.1. Assessment:* Identify and assess high risk patients with chronic disease, complex medical, and psychosoc