Requirements include working knowledge of Population Health, Accountable Care Organizations, Clinical Integrated Networks, EMRs, Value-based Contracts, CMS guidelines, Quality Measures including definition, interpretation, and documentation of inclusions and exclusions, Transitions of Care, Post-Acute Home Health Recertification, MCG Chronic Care Guidelines and Home Care Guidelines, Clinical Workflow in Primary Care Setting with ability to work with Primary Care Clinics to implement Nurse Navigation and/or Care Coordination without interruption of workflow or impacting clinician/staff satisfaction. Collaborates with Primary Care Clinics to implement Care Coordination and/or Nurse Navigation for value-based contracts; has experience with ambulatory clinic workflow with ability to partner and troubleshoot with ambulatory clinical team to develop and refine operational workflows within the practice and specific EHR; familiar with order sets, appointment templates, scheduling of procedures, and pre-authorization.