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Job DescriptionRegistered Nurse (RN) - Transitional Clinic Case ManagerPRN Day ShiftBel Air, MD1. Care coordination includes: screen and prioritize patient care needs; Assess physical/psychosocial needs and functional deficits of patients; Provide telephonic guidance; advice and support to patients; Set health improvement/health management goals for patients; Develop and maintain electronic care plan.2. Communicates and collaborate regularly with the patient's clinical team, primary care provider, and community-providers (to include home health agencies, adult protective services, and patients' family as authorized by patient) on patient needs, concerns, treatment adherence and any chan