The primary duties of this position involve facilitation of continuity of care across the healthcare continuum. This role acts as a navigator and advocate for better health outcomes for patients served by the primary care physician.  The Care Manager is responsible for managing high risk patients with multiple comorbidities or at high risk for hospital admission or readmission. This will include developing and monitoring health promotion, disease management, care coordination and utilization management. The Care manager will develop care plans in conjunction with the care team to implement interventions that assist moving the patient toward optimal health. The Care manager will facilitate care transitions after a hospital admission   to ensure the patient has a seamless experience and well coordinated care.