Population Health RN

Job description

Job Summary: The Population Health Nurse will work in collaboration with primary care providers and healthcare teams. Primary responsibilities will include the following: - Identification of Medicare patients appropriate for Annual Wellness Visits & execute guided processes to complete the visit. - Effectively coordinate & manage high-risk chronically ill patients through Chronic Care Management & Remote Patient Monitoring utilizing health coaching techniques to assist patients with self-management of their chronic diseases & lifestyle changes to mitigate health risk. - Initiate Transitional Care Management coordinating efforts with post-acute providers (Home Health, PCP, Pharmacy, SNF etc.). Essential Job Duties: - Attend and actively participate in all ACO population health related trainings and meetings including advanced health coach certification, regional workshops, webinars, roadmap and cohort calls, and one-on-one meetings, as needed - Works collaboratively with the ACO team to develop a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the provider; post reminders to secure that al...