JOB REQUIREMENTS: Provide a coordinated, strategic approach to detect early, and manage effectively, the chronically ill patient population. Implement an effective internal tracking system for identified patients. Coach patients/families toward successful self-management of their chronic disease. Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care. Assess patient and family\'s unmet health and social needs. Provide effective communications to improve health literacy. Develop a care plan based on mutual goals with patient, family, and provider\'s emergency plan, medical summary, and ongoing action plan, as appropriate. o Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed. Create ongoing processes for patients/families to determine and request the level of care coordination support they desire overtime. Promote healthy behaviors in all populations, and ensure navigation assistance with community resources. Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists, (i.e. Dietitian). Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care, and referrals. Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources. Ensure effective tracking of test results, medication management, and adherence to follow-up appointments. Develop systems to prevent errors (e.g. effective medication reconciliation and shared medical records). Facilitate attended meetings between patient, families, care team, payers, and community resources, as needed. Ability to use office equipment such as telephones, computers, printers, fax, and scanner. Ability to use medical equipment such as Blood Pressure, and EKG equipment. ***** OTHER EXPERIENCE AND QUALIFICATIONS: Previous experience in caring for chronic disease patients required. 3-5 Years\' experience in clinical or community health settings preferred. Previous Care Coordination, Case Management or Home Health experience preferred. Demonstrates evidence of essential leadership, communication, education, collaboration, and counseling skills. Proficient in communication technologies (email, cell phone, etc.). Efficient organization skills and demonstrates ability to maintain accurate notes and records. Previous experience with health IT systems and data reports preferred. Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred. Ability to identify and implement appropriate patient communication strategies, and overcome accessibility barriers, as required. ***** APPLICATION INSTRUCTIONS: Apply Online: https://lafayettecountywi.civicpluswebopen.com/hr/job-opening/primary-care-clinic-full-time-rn-care-manager