Clinical Care Coordination 1. Works with the ambulatory care management nurse to manage a case load. supporting up to 200 commercial outpatients. 2. Contributes to the Transitions of Care (TOC) process, with coordination of post-acute services for specific populations in the outpatient setting. 3. Collects data from multiple sources and works with the ambulatory care management nurse to assess patient needs. 4. Collects data in collaboration with patient, family, physician, health care team and works with the ambulatory care management nurse to develop a plan of care. 5. Collaborates with the ambulatory care management nurse to ensure a specific plan of care is in place for all patients. Assist the ambulatory care management nurse to the timely completion of all delegated assigned tasks, from the associated plan of care. Provide coordination of care such as schedule members’ appointments; arrange transportation, etc. as outlined in policy and procedures. 6. Actively participates in interdisciplinary meetings and team huddles. 7. Answer phone calls from providers, facilities, or patients, related to the status and processing of requests received from ambulatory care management nurse. 8. Assists with data collection for ongoing discharge planning needs, documents changes in computer system under the direction of the ambulatory care management nurse. 9. Demonstrates collaborative working relationship with social workers to ensure patient psychosocial needs are met. 10. Demonstrates collaborative working relationship with care team members, including pharmacy, behavioral health, field team, office staff, and facility staff.