Population Health Nurse/Social Worker

Position/Job Title:               Population Health Nurse/Social Worker

Reports to:                            Population Health Manager

Posting Date:                        05/07/2026

Job Code:                              310

Pay Class/Status:                 Professional-Licensed - Exempt

Summary: 

Reporting to the Population Health Manager, the Population Health Nurse/Social Worker is responsible for the implementation of Integrated Health Partners’ (IHP) Population Health program with diverse job functions designed to meet specific contractual and program-related requirements and improve patient outcomes. This role focuses on improving the health status and care for individuals with medical, behavioral health, and psychosocial needs as well as lifestyle support. The staff member provides group and individual education and mentoring to support sustainable programs to improve patient outcomes.  

Essential Functions:

Primary responsibilities will include the essentials functions listed below:

• Engages patients in episodic and longitudinal care management and/or collaborative behavioral health care management through in-person, virtual, and telephonic interactions, including post discharge management.
• Assesses individual needs and develops care plans to address needs related to preventive and chronic illness, behavioral health condition(s), psychosocial needs, and overall health.
• Works collaboratively with primary care provider, behavioral health consulting psychiatrist, when applicable, and other care team members to ensure comprehensive and coordinated patient care, including access to payer and community resources.
• Conducts patient education regarding condition and symptom management, red flag warning signs, and the importance of adhering to medications and evidence-based care guidelines.
• Monitors and manages patient transitions of care from inpatient and emergency settings, including medication reconciliation.
• Establishes self-management goal(s) and condition-specific action plans with patients using self-management support concepts and motivational interviewing techniques. 
• Actively participates in IHP and/or community-based initiatives related to care management, collaborative behavioral health care management, transitions of care, and wellness visits.
• Utilizes data from multiple sources to identify patients targeted for outreach.
• Conducts Medicare annual wellness visit assessments.
• Outreaches and enrolls eligible participants in health coaching to improve health status and reduce or eliminate behaviors that place the participant at risk for adverse health outcomes. Fosters trust with participants to increase participant motivation to facilitate behavior change and adoption of habits that are conducive to a higher quality of life.
• Documents patient interactions and appropriately selects billing codes in a timely manner. Monitors claim paid activity reports and troubleshoots billing concerns.
• Participates and leads individual and group educational and mentoring activities at the physician practice and organizational level.

Additional Responsibilities/Duties:

The following examples are intended to be descriptive but not restrictive.

• Conducts audits and studies as directed and prepares associated reports.
• Represents IHP on state, regional, and community groups.
• Participates in culture development and building a strong team for delivering IHP’s mission.
• Demonstrates commitment to providing outstanding customer service in a manner that is reflective of IHP’s mission, vision, values, organizational context, code of conduct, and customer service standards.
• Identifies opportunities for continuous improvement, develops related plans of action, and implements process and documentation improvements.
• Pursues and engages in continuing professional development.
• Maintains a working knowledge of applicable Federal, State and local laws and regulations, IHP’s Compliance Program & Code of Conduct, ERISA, HIPAA privacy, transaction and code set requirements, as well as other policies and procedures, in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
• Performs related duties as assigned.

Education/Experience:

Required Education and Experience:

• Registered Nurse (RN) or Licensed Master Social Worker (LMSW) with current Michigan license in good standing required.
• Three (3) years clinical experience.
• Experience and/or ability to work with diverse populations.

Preferred Education and Experience:

• Bachelor’s degree in Nursing or Licensed Master Social Worker.
• Experience in education, case management, chronic care nursing, community health, or as a certified health coach.
• Experience in ambulatory care, home health, behavioral health, physician practice, quality improvement, or other community setting.

Professional Competencies, Licensure/Certification, Etc.:

Competencies:

Interpersonal skills                                                    Grammar and spelling skills

Proven customer relations skills                                Problem solving skills

Motivational interviewing skills                                Computer skills

Organizational and prioritization skills                     Microsoft Excel, Word, PowerPoint     

Basic math skills                                                        Time management skills     

Demonstrate and maintain high level of accuracy    Analytical skills

Conflict resolution skills                                          Strong attention to detail                                  

Ability to work well under pressure  

Clear and assertive written and verbal communication        

Licensure/Certification/Training:

• Registered Nurse (RN) or Licensed Master Social Worker (LMSW) with current Michigan license in good standing.

Work Environment:

This job operates in a hybrid schedule between professional office environment and options for working from home. This role routinely uses multiple electronic health records, patient registry, and standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

This is largely a desk-bound role; however, frequent movement throughout the office is required. Frequent sitting, standing, and walking are daily activities. Some bending and filing may be required. This would require the ability to lift files, open filing cabinets and bend or stand as necessary

Position Type/Expected Hours of Work:

This is a full-time position. Days and hours of work are Monday through Friday. Hours of operation are typically 8:00 a.m. to 5:00 p.m. with some scheduled evening events. Work hours may vary by position with some positions requiring extended workdays depending on business needs. A typical work week for an exempt position averages 45 hours worked per week.

Travel:

This position requires up to 25 percent travel. Majority of travel will be in Southwest Michigan; however, additional travel may be required as needed. This job may have additional requirements for working on-site or embedded within a member practice or business partner and will be considered an alternate work site. Additional requirements may vary based on facility or regulatory requirements for the alternate work site.

The above statements are intended to describe the general nature and levels of the work performed and are not exhaustive lists of all duties, responsibilities, knowledge, skills, and abilities and working conditions associated with the job. As changes occur IHP reserves the right to modify the above description.