What are the responsibilities and job description for the Population Health RN position at Good Samaritan Hospital?
Job Info
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 all co-morbidities are discussed and documented during AWV
- Attend and actively participate in all Value Based Contract meetings, trainings & patient outreach
- Stratify patient population according to risk score. Effectively and efficiently manage patients with multiple chronic diseases; Identify patients appropriate for Chronic Care Management (CCM). In collaboration with the PCP, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to care plan and progress toward goals and facilitate changes as needed.
- Ensure sharing of positive patient stories or compliments involving care team efforts
- Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, transition of care follow-up calls/visits, CCM encounters, navigate care for patients enrolled in RPM
- CMA oversight as directed by Quality & Care Coordination Manager
Secondary Job Duties That May be Reassigned:
- Perform other related duties as directed by Quality & Care Coordination Manager & Executive Director, Good Samaritan Physician Network
Job Specifications:
- Current licensure as a Registered Nurse
- Minimum of five years of clinical experience required, with at least two years in a physician/group practice or other ambulatory or outpatient setting
- Previous Care Coordination, Case Management, Home Health or Behavior Health experience preferred
Posting Date: 2026-08-27T12:49:29 00:00
Job Schedule: Full time
Job Shift:
Locations: 520 S 7th St Vincennes IN 47591