POPULATION HEALTH RN CASE MANAGER: Serves as a clinical resource for patients and families enrolled in Population Health Management programs such as Enhanced Care Management (ECM), Chronic Care Management, Transitional Care Management with goal of improving health outcomes, reducing unnecessary healthcare utilization and addressing Social Determinants of Health (SDOH) in partnership with a multidisciplinary team to include Primary Care Provider, Community Care Coordinator, Pharmacist, Medical Assistant, etc. Interviews, researches and gathers data to identify patient's needs and formulate a post-acute plan of care in collaboration with the patient, family, physician, acute case manager and other disciplines which enhances appropriate utilization of post-acute levels of care.