The RN Case Manager will facilitate appropriate care coordination to patients and their families in cases where specific problems related to clinical aspects influence effective utilization of inpatient or outpatient treatment (e.g. organize and facilitate access to tests, procedures, and results to prepare patient for discharge); will assist in the formation and/or implementation of the patients discharge plan, as related to clinical assessments; serve as a liaison with other departments and agencies to ensure continuity of transition of care; make recommendations based on evidence/practices that best aligns with the clinical needs of the patient (e.g. arranges home health, durable medical equipment, or infusion therapy, and complete referrals to appropriate agencies); serve as a resource by providing training and education about case management services; work in tandem with SW-Case Manager and refer high risk patients to them; and participate in departmental coverage.