Population Health Nurse
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Description
Position Overview
The Population Health Nurse coordinates Medicare Annual Wellness Visits (MAW), Chronic Care Management (CCM), Accountable Care Organization (ACO) support, and value-based care activities. This role identifies eligible patients, conducts RN-led wellness visits, develops and manages patient-centered care plans, coordinates follow-up and care transitions, and supports quality improvement, positive patient experiences, and effective chronic-condition management.
Essential Functions
The essential functions may include, but are not limited to the following:
- Supports and adheres to the Organizations Mission, Vision, and Values.Coordinates Medicare population health activities, including Medicare Annual Wellness Visits (MAW), Chronic Care Management (CCM), Accountable Care
- Organization (ACO) initiatives, and other value-based care programs.
- Identifies eligible patients, coordinates outreach and scheduling, and supports management of attributed Traditional Medicare and Medicare Advantage populations.
- Conducts RN-led MAW encounters, completes related clinical assessments and documentation, and identifies preventive, chronic-care, medication, cognitive, functional, behavioral, social, and safety needs requiring follow-up.
- Develops and manages comprehensive, patient-centered CCM care plans; provides ongoing care management, monitors progress and supports patient engagement and self-management.
- Coordinates referrals, care transitions, preventive services, and follow-up with patients, providers, care-team members, specialists, and community resources.
- Identifies and escalates clinical concerns, changes in condition, abnormal findings, safety risks, and needs requiring provider involvement or evaluation beyond approved protocols.
- Supports ACO and value-based care requirements, including care-gap closure, clinical documentation, payer submissions, and coordination of required services.
- Monitors patient participation, program activity, quality measures, care-coordination outcomes, utilization, and performance indicators to identify barriers and opportunities for improvement.
- Maintains accurate, timely, and complete documentation in Epic and other approved systems in accordance with FHC policies and applicable requirements.
- Participates in audits, workflow education, competency validation, and performance-improvement activities.
- Performs other duties as assigned. Other duties may be added, and this job description may be amended at any time.
Work-Related Experience
- Clinical experience in primary care, ambulatory care, population health, care management, chronic disease management, or a related healthcare setting is required.
- Experience conducting patient assessments, providing chronic-disease education, performing medication reconciliation, coordinating care, and recognizing changes in condition is required.
- Experience developing care plans is preferred.
- Experience with Medicare Annual Wellness Visits, CCM, Federally Qualified Health Center (FQHC) operations, Patient-Centered Medical Home (PCMH), ACO, or other value-based care programs is preferred.
- Experience using an electronic health record (EHR) is required; Epic experience, including registries, work queues, referral workflows, or population-health tools, is preferred.
Physical Demands and Work Environment
Mental:
- Ability to remain calm and effective in high-stress or unpredictable situations.
- Strong critical-thinking, problem-solving, organizational, and decision-making skills.
- Ability to prioritize responsibilities, manage competing demands, and adapt to changing needs.
- Ability to communicate clearly and professionally, both verbally and in writing.
- Ability to exercise sound judgment, maintain confidentiality, and handle sensitive information appropriately.
- Ability to recognize changes in patient condition and escalate concerns appropriately within the RN's scope of practice.
Physical:
- Frequent standing, walking, and occasional lifting of patients or equipment (up to 20 lbs).
- Ability to perform repetitive motions, including typing for EHR documentation.
- Frequent standing, walking, and reaching to provide patient care.
- Occasional exposure to bodily fluids, infectious diseases, and hazardous materials; adherence to infection control protocols is required.
- Prolonged sitting at a desk with frequent computer use.
- Ability to conduct patient interviews and assessments and move throughout clinical and office areas.
- Ability to perform the essential functions of the position with or without reasonable accommodation.
Working Conditions:
- Outpatient clinical and professional office environment.
- Frequent interaction with patients, caregivers, providers, staff, payers, and external partners.
- Potential incidental exposure to healthcare environments; adherence to applicable safety and infection-prevention requirements is expected.
- Occasional travel between Family Health Center locations will be required.
Education, Certification, and Licensure
Education: Graduate of an accredited registered nursing program required.
Certification: Current Basic Life Support (BLS) certification required or obtained within the organization's required timeframe.
Licensure: Current, unrestricted Indiana Registered Nurse (RN) license required.
Skills
- Demonstrates clinical assessment, critical-thinking, patient-education, and appropriate escalation skills.
- Knowledge of Medicare preventive services, chronic disease management, comprehensive care planning, medication reconciliation, care transitions, and referral coordination.
- Ability to communicate effectively with patients, caregivers, providers, clinical teams, payers, specialists, and community organizations.
- Ability to use motivational interviewing, patient-centered goal setting, health-literacy principles, and culturally responsive communication.
- Ability to maintain accurate EHR documentation, reconcile time-based activity, manage work queues, and track patient and program outcomes.
- Ability to review data, identify barriers and trends, and translate findings into practical follow-up actions.
- Excellent judgment, attention to detail, adaptability, reliability, confidentiality, and the ability to work independently within approved protocols and scope of practice.