Population Health Nurse

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.

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.

• 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.

• 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…