The Care Coordination Nurse Case Manager (CC RN) is part of the primary care team and directly supports OCHS’s highest risk patients in the community. In collaboration with other members of the healthcare team, the CC RN is responsible for organizing, coordinating, and providing care coordination and care management services to patients who are most at risk for health deterioration, avoidable hospital or ED visits, and/or poor outcomes. The CC RN performs primarily telephonic care management with face to face engagement in the clinic and/or home visit for some selected situations. In collaboration with the primary care team, the CC RN develops care plans to promote self-management goals, adherence to treatment plan, prevent disease exacerbation, decrease risk status, minimize hospital and ED utilization, and improve outcomes.
