The Care Manager RN develops and implements individualized care plans, provides clinical assessment and education, conducts telephonic and in-home care management visits as appropriate, supports transitions of care, and collaborates with primary care providers to improve quality, patient experience, and health outcomes. The Care Manager RN partners closely with the Medical Director, Advanced Practice Provider (APP), Licensed Clinical Social Worker (LCSW), Community Health Worker (CHW), Pharmacist, and Care Navigators to coordinate care for patients with complex medical, behavioral, and social needs.