Ensures continuity and coordination of care across transitions; hospital discharges (TCM metric) , medicare wellness exams and chronic care management program for all Family Practice and Internal Medicine practices. Identifies other care barriers and facilitates optimal care delivery, and develops a comprehensive plan to address patient needs. Works closely with the Regional Quality of Care RN. Associates degree required. Bachelors of Nursing preferred. RN Licensure in state of proactive. Min 2 years of experience.