REGISTERED NURSE - SCC POPULATION HEALTH / ACO

Job Title

Population Health / ACO Registered Nurse (RN)

Department

Population Health / ACO

Full Time/PRN

Full Time

Job Summary

The Population Health/ACO RN manages and improves health outcomes for patient populations through care coordination, evidence-based interventions, chronic disease management, preventive care, and patient engagement within a value-based care environment.

Minimum Qualifications

• Current and valid Registered Nurse (RN) license.
• Minimum of 2 years of clinical nursing experience, preferably in population health, case management, or care coordination.
• Strong knowledge of chronic disease management and preventive care principles.
• Familiarity with EHR systems and healthcare analytics tools.
• Excellent communication and interpersonal skills.

Preferred Qualifications

• Certification in Case Management (CCM) or Population Health Nursing.
• Experience working within an ACO or value-based care environment.
• Background in community health nursing or public health.
• Proficiency in motivational interviewing and patient engagement techniques.
• Advanced training in quality improvement methodologies and healthcare regulations.

Essential Duties & Responsibilities

• Conduct comprehensive patient assessments to identify health risks and care needs.
• Develop, implement, and monitor individualized care plans.
• Coordinate care transitions and follow-up activities to reduce avoidable readmissions.
• Utilize population health data to identify trends, care gaps, and intervention opportunities.
• Provide patient education and support for chronic disease self-management.
• Serve as a liaison between patients, families, and healthcare teams.
• Participate in quality improvement initiatives and support CMS and ACO performance metrics.
• Document patient interactions, care plans, and outcomes in the EHR.
• Perform additional duties as assigned by leadership.

Professional Responsibilities

• Apply clinical expertise and critical thinking to patient care planning.
• Collaborate effectively with multidisciplinary healthcare teams.
• Utilize data analytics and population health tools to improve outcomes.
• Promote preventive care and address social determinants of health.
• Support organizational quality, compliance, and value-based care initiatives.

Physical Requirements

• Ability to sit, stand, walk, bend, and perform patient assessments throughout the workday.
• Frequent use of computer systems, telephones, and electronic documentation tools.
• Ability to communicate effectively with patients, families, and healthcare professionals.