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.

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…