**Job Description:**

The Registered Nurse (RN) is a professional caregiver who assumes responsibility and accountability for assessing, planning, implementing and evaluating care of patients. The staff RN utilizes the nursing process by use of technology, therapeutic intervention, evidence-based practice and coordination of care with other health team members.
**Essential Functions**

+ Patient Identification and Assessment: Identifies patients for proactive interventions using specific screening criteria, medical record review, payor models, medical risk scores, or referrals. Assesses patients' medical, functional, and social conditions per department policy/guidelines to develop individualized care plans, care recommendations, or referrals as appropriate.

+ Care Plan Management: Coordinates with internal and external services for social determinants of health (SDoH) needs and care in the community. Evaluates the effectiveness of the patient’s care plan an...