Under limited direction and according to established policies and procedures, provides care coordination services to patients, families or post acute care givers. Patients appropriate for services may have acute or chronic conditions including, but not limited to, Diabetes, Cardiac Arrhythmias, Coronary Artery Disease, CHF, COPD, Recent Stroke, Short or long term anticoagulation or Renal Failure. Functions as a facilitator of inter-disciplinary collaboration across care transitions. Coaches target patient populations and their caregivers to assume an active role in the formation and execution of a plan of care, encourage self management, and assist in coordination of communication between the patient, caregivers and primary care providers. Assesses patient and family understanding of disease process and reinforces discharge teaching including red flags that signal the patient that their condition may be worsening and how to respond. Collaborates and communicates with care providers both internal and external to coordinate service delivery and achieve optimal patient outcome of care. Collaborates and communicates with hospital care management teams to coordinate post acute care plan of care. Collaborates and communicates with attending physician regarding patient's post acute needs. Creates and maintains a Patient Centered Record that consists of the essential elements for facilitating productive interdisciplinary communication throughout any care transition or patient handover including disease specific education, community resources, adherence to evidence based practice, discharge checklists and medication reconciliation. Evaluates and improves care processes across patient populations. Problem solves care issues and concerns with patient and family.

1.Graduate from an accredited school of Nursing. Bachelor's degree in Nursing (BSN) or other health-related field, or equivalent combination of education and or related experience. 2. Licensed to practice as a Registered Nurse (RN) in the State of Michigan. 3. Two years of clinical patient care experience. 4. Two years of case management or care coordination experience. 5. Experience with Lean or similar process improvement methodology.

Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.