Triages, coordinates and facilitates the clinical management for an assigned population. Develops, monitors and reinforces care standards and protocols designed to enhance quality and promote cost-effective utilization of healthcare resources.

1. Facilitates the development of a plan of care in collaboration with the patient, family, caregiver and health care team. This is done through early identification and thorough assessment of the patient’s need/preferences and resources available. Determines the appropriate level of care and coordinates the interdisciplinary treatment and plan of care.
2. Facilitates the progression of care by advancing the care plan to achieve desired outcomes. Monitors the progress towards the goals of the plan and alerts the health care team to potential revisions to the plan in response to the changes in the patient needs and condition.
3. Triages telephone calls and responds to patients and families and other members of the healthcare teams questions that are within a registered nurse’s scope of practice.
4. Communicates information to the health care team and those involved in the treatment and patient’s care.
5. Advocates on behalf of patients/families and caregivers for service access and insurance benefits within the constraints of regulations, and for the protection of the patient’s health, safety and rights.
6. Recognizes situations that require referrals to Quality, Risk Management, or Patient and Family Relations and discusses with leadership.
7. Evaluates the options available and balances cost and quality to assure the optimal clinical and financial outcomes. Facilitates progression to appropriate levels of care.
8. Evaluates patient outcomes affected by the care management process for improvement opportunities. Identifies potential for and participates in quality improvement initiatives within the clinical setting or other organizational committees.
9. Works with the clinical research to coordinate care for patients on complex protocols.
10. Performs other duties as required or assigned.