Must have the knowledge and skills to effectively apply the following core case management functions: a) Assessment: Identification of patients for case management; comprehensive collection of patient information and medical status; and continued evaluation of an established plan of care; b) Planning: Collaboration with the patient, family/caregiver, primary provider and other members of the health care team for developing an effective plan of care; c) Facilitation: Care coordination and communication among all involved parties; d) Advocacy: Support for the patient and family/caregivers to ensure identified education and appropriate, timely care is received. Develop and implement local strategies using inpatient, outpatient, onsite and telephonic CM• Develop and implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, and databases for community resources.•