Population Health Facilitator - LPN

Caring For the Community You Love 

Choose a career to make a difference in people's lives every day, choose Fisher-Titus!

Perks of working at Fisher-Titus:

• Hours of Work- Full time


• Comprehensive Benefits Package- Medical & Dental coverage, 401K match, paid time off, tuition assistance and more!


• Shift, Weekend & PRN differential

About Fisher-Titus:

Fisher-Titus proudly serves the greater Huron County area’s 70,000-plus residents by providing a full continuum of health and wellness care from heart and cancer care to outpatient services such as lab, imaging, and physical rehabilitation.

Vision: Be the first choice for healthcare and employment within our community 

Mission: Deliver compassionate and convenient care to the highest level of excellence that promotes lifelong health and wellness for our community

General Summary:

The Care Navigator connects with the patient via telehealth, phone, or in person and introduces the TCM program within 1-2 business days after discharge to review discharge instructions, medication reconciliation, social determinants, and assist with appointments as needed. The CCM Care Navigator manages identified patients through the initial face to face encounter, referrals from ambulatory providers or inpatient providers, then is responsible for: assessment, comprehensive care plan and creates patient centered goals in collaboration with the patient and physician. Continued contact is maintained through telephonic and electronic communication based on the needs identified in the comprehensive care plan. The Care Navigator will demonstrate performance consistent with the professional standards of practice.

Essential Functions:

• Identify appropriate patients for TCM/CCM. Review with the patient and/or family the program's services and benefits. Review and answer questions relating to the program's consent requirements.


• Assists in conjunction with the patient and/or family and health care team the development an individualized comprehensive care plan. Provide needed patient education regarding specific health care skills and general disease concepts by supplying informational materials, directing the patient to health plan resources, approved websites or community resources.


• Document services provided in the record appropriate for reimbursement. Review medication list and identifies area to be reconciled.


• Schedule routine and follow-up appointments as indicated.


• Refer and/or connect patients to appropriate community and health related services. Make appropriate referrals to the care team. Able to identify social determinants and provide community resources as appropriate.


• Involve the patients in activities to improve their health by providing education and support to the patient about self-management tasks they can undertake to gain greater control of their health status.


• Manage patient care in the health care continuum to achieve optimum outcomes in a safe and cost-effective manner. Address open quality gaps with patients and work collaboratively with patient towards closure of those gaps. Appropriately document within the electronic record to satisfy closed quality gaps.


• Monitor minutes of services provided to ensure appropriate time is completed for billing. Completes monthly billing in a timely manner.


• Builds and maintain strong, healthy relationships with clinical teams; Developing and sharing knowledge of CCM/TCM eligibility and documentation requirements with healthcare team.

Although, primarily performed by a RN, the role of a Chronic Care Navigator can be accomplished as an LPN with understanding that salary will be established at an LPN level.  RNs have the responsibility of enrolling patients into CCM and making the initial call for a TCM.

This position will cover Bellevue, Milan, and New London locations. Remote work may be considered.