OverviewResponsible for providing patient case management services to assigned populations. They use a collaborative interdisciplinary approach to anticipate, integrate, and coordinate the patient's care plan, discharge plan, and reentry into the community. The primary goal is to meet patients' needs to optimize clinical and resource outcomes while monitoring the plan's effectiveness. In collaboration with the clinical team, identifies patients who would benefit from case management services. They perform assessments to identify patient needs and barriers, assisting in the development of the care plan. Acting as a patient and family advocate, serves as a communication link between the physician, patient, family, healthcare team, community resources, and payers to