Assists in conducting health risk assessments (HRAs) and reviews of patient records and/or claims analysis to identify care management and care coordination services Collaborates with other Case Managers, when applicable, to ensure smooth handoffs of patients from case manager to case manager and to all involved caregivers across the continuum Provides and manages care management and care coordination services in a timely, efficient, and cost-effective manner to meet patient-specific clinical and social needs Assists in developing patient care plans and care goals Monitors patient progress in relation to care plans and expected outcomes Actively engage as an integral, collaborative member of the patient's care team Communicates with and disseminates information to the patient, PCP, and other care team members to ensure consistent, seamless, and coordinated care Facilitates care coordiation for the patient across the care continuum, ensuring that the patient is receiving the highest level of quality Advocates consideration of all options available to ensure quality of care in the most cost-efficient manner Refers patients to appropriate and available resources to meet identified needs Supports processes to ensure that appropriate authorizations, referrals, and payor requirements are obtained and met to allow patient care Actively involve patients/caregivers in their healthcare and encourage shared decision making. Certifications: Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)Illinois Department of Financial and Professional Regulation (IDFPR); Basic Life Support (BLS) within 30 days - American Heart Association (AHA)American Heart Association (AHA), Education: Certificate of Completion: Related Field; Bachelor's Degree: Nursing, Work Experience: Nursing .