The RN Care Manager uses the nursing process and evidence-based practice to collaborate with the Patient Aligned Care Team (PACT) (Patient, Primary Care Provider, RN Care Manager, Clinical Associate, and Medical Support Assistants) and Expanded Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven holistic care plan for life. Duties include but are not limited to: The RN will be responsible and accountable for all elements of the nursing process when providing and or supervising direct patient care within the respective PACT. Assess, plans, implements and evaluates care based on age-specific components. Assumes responsibility for the coordination of care focused on patient transitions through the continuum
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