Hours of Work This is a full time, 40 hour per week position with standard working hours of 8:00 a.m. to 4:30 p.m. , Monday through Friday. Routine weekend and holiday work is not expected. However, occasional weekend hours may be required to support special events, organizational initiatives, emergency operations, or other business needs. Duties and Key Responsibilities Collaborates with physicians to develop a standard of care with preventative services and chronic disease management. Incorporates patient improvement initiatives to meet individual goals as developed by the provider. Conducts outreach through telephone, secure email, or postal mail with the goal of engaging enrollee and closing gaps of care. Actively manages assigned panel of chronic care patients. Actively participates with community-based initiatives related to care management and transitions of care. Assessing barriers when patients are not meeting treatment goals, not following treatment care planning, or having issues keeping important appointments. Assists in the smooth transition of care for patients treated in a facility (inpatient or emergency department), by a specialty physician, or by another healthcare provider to the home environment. Committed to following the customer service values as defined in The Grand Experience. Collaboration with insurance payers for gap closure to increase star ratings. Requirements Must exhibit versatility in order to meet deadlines and coordinate complex work facets simultaneously. Requires excellent interpersonal skills in dealing with patients, families, outside regulatory agencies, hospital personnel, and medical staff. Strong ability in both verbal and written communication skills. Strong computer skills Proficiency in Microsoft Office products i.e.: Word, Excel, Outlook Education/Certifications Associates degree in nursing is required. Must hold an active RN license. Experience 2-3 years of clinical nursing experience. Preferred physician office experience, population health, quality improvement and case management experience Experience with health coaching or possesses a health coach certification is a plus. Grand Lake Health System provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. GLHS complies with applicable state and local laws governing nondiscrimination in employment in all of our locations. In addition, Grand Lake Health System is an At-Will Employment employer. Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.