Summary: The RN Case Manager works collaboratively with patients, nurses, social workers, physicians, other practitioners, caregivers, and the community to facilitate care along a continuum with the goal to achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient's right to self-determination. F.Communicates continually with physicians, patients, caregivers, and care team members to facilitate coordination of clinical activities to enhance a seamless transition from one level of care to another.