Population Health Nurse

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.