This will include: Managing the ongoing care management for an assigned population case load (Population Health Management), Performing Comprehensive Risk Assessments and developing individualized Patient Care Plans for all assigned cases, Managing and coordinating patient access to care, including overseeing the efforts of collaborating Care Coordinators, Referral staff and others, Addressing all relevant Transitions of Care management when patients obtain hospital-based care, and. Under the general guidance of the Director of Care Management, the Nurse Case Manager will provide direct patient care through implementation of individual patient care plans developed in collaboration with the patient's primary care provider.