The Nurse Case Manager may provide daily care coordination, case management, coaching, consultation and intervention to patients with one or more chronic diseases. May also be responsible for identifying said population via provider/clinic referral, utilization management referral, disease registry reporting mechanisms and patient self-referral. This position may also provide case management to patients who are admitted to the hospital and those patients who may need to be enrolled in ambulatory case management. The case manager will be responsible for identifying (California Children Services) CCS cases, handle transfers, and retro reviews. Works as part of an interdisciplinary care team coordinating social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc. The Nurse Case Manager effectively collaborates with the hospitalist, the hospital nursing personnel, with members of the interdisciplinary care team and with the physician in the clinic.