Annual Wellness Nurse​/Population Health Facilitator

Annual Wellness Nurse/Population Health Facilitator

Job Category: Ambulatory

Requisition Number: ANNUA
005187

• Posted :
  December 8, 2025
• Full-Time
• On-site

Showing 1 location

Milan, OH 44846, USA

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!

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 Annual Wellness Nurse/Pop Health Facilitator works collaboratively with physicians and the care team to ensure patient adherence to the medical plan of care and/or evidence-based medicine guidelines, including all appropriate preventive and disease-specific screenings, interventions, and treatment goals; including self-management goals, and contact schedules.

Essential Functions:

• Communicate with populations of patients via telephone, electronically, correspondence or otherwise to support patient adherence to plan of care and/or evidence-based medicine guidelines.
• Maintain an active case load of "at risk" patients using identification and stratification tools, direct referrals from the patient's healthcare team (physician, Care Coordinator, hospital case manager, etc.) and other clinical knowledge.
• Work with "at risk" patients and families on self-management support including:
  Setting short and long-term goals for self-management of chronic disease. Addressing medication adherence in patients not meeting outcome goals. Creating a plan for health behavior change.
• Performing individual needs assessment, care plan design, documentation and implementation, and evaluation of outcomes.
• Communicating with patients face-to-face, by telephone, or by email.
• Communicating a plan for healthcare needs between physician/office visits.
• Providing 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.
• Working toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.
• Floats and/or works at other locations to support operational needs.

This position requires expertise in the nursing process, using critical thinking skills to plan and coordinate care. The AWN is responsible and accountable for direct and indirect patient care for designated patient populations.

Although, primarily performed by a LPN, the role of an Annual Wellness Nurse can be accomplished as an RN with understanding that salary will be established at an LPN level.

High School or better.

LPN or RN required

Certification CPR

Licensed Practical Nurse

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.