Population Health Nurse; RN or LPN

Principal Function

The Population Health Nurse serves as a clinical lead for WCCH's chronic-disease population health hub. The nurse translates registry, care-gap, utilization, and Remote Patient Monitoring (RPM) data into clinically appropriate outreach and intervention; develops and maintaining nursing and RPM workflows, coordinates the clinical work of the Case Manager, Community Health Worker (CHW), providers, pharmacy, informatics, and other staff, and helps ensure that patients with complex chronic conditions receive proactive, evidence-based, coordinated care.

The nurse provides nursing assessment, education, clinical escalation, and quality oversight within the individual's licensed scope and WCCH clinical policies, while partnering with the Case Manager and CHW so clinical needs and nonclinical barriers are addressed by the appropriate team member.

• 1. Assist in the development, implementation, and ongoing management of a chronic-disease population health hub focused on diabetes, hypertension, cardiovascular disease, obesity, tobacco-related illness, and other high-risk conditions.
• 2. Use population health registries, risk-stratification tools, utilization information, and electronic health records (EHR) data to identify patients requiring preventive services, chronic-disease management, nurse follow-up, or targeted intervention.
• 3. Develop and maintain clinical RPM workflows, including patient-selection criteria, consent, monitoring frequency, alert thresholds, escalation pathways, documentation requirements, emergency instructions, and coverage expectations.
• 4. Provide clinical oversight to RPM by reviewing escalated readings and trends, completing nursing assessment and intervention within license scope and promptly involving the appropriate provider when clinical decision-making or treatment changes are needed.
• 5. Direct and coordinate the Case Manager's support of RPM enrollment, device onboarding, adherence outreach, routine dashboard workflow, and follow-up, while maintaining clear nursing and provider escalation pathways.
• 6. Lead interdisciplinary population health huddles and coordinate work among the Case Manager, CHW, providers, clinical pharmacy, informatics, laboratory, radiology, Street Medicine (RN), transportation, medication-access and other staff.
• 7. Provide nursing assessment, individualized clinical care planning, patient education, and chronic-disease self-management support within licensed scope and established protocols.
• 8. Conduct or coordinate timely clinical follow-up for abnormal results, medication concerns, hospital or emergency-department transitions, worsening symptoms, and high-priority care gaps.
• 9. Collaborate with providers and pharmacy staff on medication adherence, reconciliation, treatment plan implementation, and clinical escalation high-risk patients.
• 10. Identify social determinants of health and other practical barriers affecting the clinical plan; make a warm handoff to the CHW for community navigation while maintaining responsibility for appropriate clinical follow-up.
• 11. Collaborate with hospitals, specialists, health departments, behavioral health organizations, and other regional clinical partners to strengthen referral, transition-of-care, escalation, and information-sharing pathways.
• 12. Assist in developing community-based, mobile, and telehealth-enabled clinical workflows that expand access while maintaining safety, privacy, documentation, and continuity standards.
• 13. Validate clinical definitions and data quality with informatics; track and report clinical quality measures, patient outcomes, RPM activity and response, care-gap closure, referral completion, and program performance.
• 14. Maintain accurate, timely, and complete documentation in the EHR, RPM platform, and other required systems in accordance with organizational policies and regulatory requirements.
• 15. Participate in quality improvement, protocol review, staff training, and continuing education related to chronic-disease management, RPM, population health, value-based care, and regulatory requirements.

This job has no formal personnel-supervision responsibilities unless specifically assigned. This position provides clinical workflow direction and day-to-day coordination to Case Managers and CHW's with WCCH policy and the incumbent's licensed scope.

• Graduate of an accredited practical-nursing or registered-nursing…