Responsibilities: A day in the life of a RN, Community Based Care Management at Hackensack Meridian Health includes: Effective provides/facilitates the following education & advocacy support: Education: Complete needs assessment, formulate and carry out a comprehensive teaching program -Promotes patient engagement, self-management, and shared decision making -Establishes relationship with patients and caregiver, if any -Translate care choices and treatment plans. Identify high-risk patients, assess clinical and psychosocial needs, make referrals to ancillary providers (disease management, pharmacy, social work, palliative care, community-organizations, non-clinical services), develop care plan in coordination with PCP, engage and activate patients.