Hours of Job FT or PT - Shift No weekends or holidays required Duties and Key Responsibilities Participates in our patient-centered medical home by collaborating with physicians to developing 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 face to face follow up, telephone, secure email, or postal main 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 have not kept important appointments. 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. 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 preferred. 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.