Job Details: Job Location: 19047 PINNACLE FAMILY MEDICINE - JOHNSON CITY, TN, Position Type: Full Time, Salary Range: Undisclosed, Job Category: Clinical , WHO WE ARE: State of Franklin Healthcare Associates is a physician-led and employee-owned multi-specialty care group headquartered in Johnson City, TN with locations in the upper East Tennessee & Southwest Virginia region.  Our mission is to improve the health and well-being of our patients and our team members.   PRIMARY RESPONSIBILITIES: Help patients transition from an inpatient setting back home or to a post-acute setting. Development, initiating, and monitoring of a plan of care for the patient self-management. Utilize knowledge of motivational interviewing techniques to enhance patient outcomes. Access, plan, implement, monitor, and evaluate options and services required to meet patients’ needs. Identify social determinants of health and refer patient of community resources and social worker support. Accurately document in the medical record and CareTrac. Assist providers with closing care gaps through patient outreach. REQUIREMENTS: Must be a graduate of an approved school of nursing. EXPERIENCE: Minimum of two years’ experience, preference given to a similar role.   CERTIFICATES, LICENSES, REGISTRATIONS: Licensed in the state of employment.   WHAT WE OFFER: State of Franklin Healthcare provides a comprehensive and competitive total compensation package designed to meet the needs of our full-time team members to include: Company Provided Life and Accidental Death and Dismemberment Insurance Company Provided Long Term Disability Insurance Employee Stock Ownership Plan  401(k) Company Contributions Voluntary options for Medical, Dental, Vision, and additional Life Insurance. Company match in Health Savings Account Plans (restrictions apply) Vacation, Personal, Sick and Holiday Time Off An array of team member perks and discounts Tuition Assistance Programs And more! Qualifications: