Effectively navigate established Population Health/ACO initiatives with input from the Population Health Coordinator, medical staff, and other operational leaders by facilitating essential preventive care services to reduce the severity of chronic disease and avoidable acute illness. Coordinate and provide, personalized healthcare services to individuals through effective partnerships with patients, their caregivers/families, community resources, and their physician. Current licensure as a Registered Nurse required. Previous experience in caring for chronic disease patients required. 3-5 years experience in clinical or community health settings, Care Coordination, Case Management or Home Health experience preferred.