REGISTERED NURSE - SCC POPULATION HEALTH / ACO
About The Position
The Population Health/ACO Registered Nurse manages and improves health outcomes for patient populations in a value-based care environment. The role focuses on care coordination, evidence-based interventions, chronic disease management, preventive care, and patient engagement. The RN assesses patient risks and care needs, develops and monitors individualized care plans, coordinates transitions and follow-up, provides education, and uses population health data to identify care gaps and intervention opportunities. The position also supports quality improvement, CMS and ACO performance metrics, compliance, and value-based care initiatives.
Requirements
- 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.
Nice To Haves
- 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.
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.
- Use 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.
- Apply clinical expertise and critical thinking to patient care planning.
- Collaborate effectively with multidisciplinary healthcare teams.
- Use 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.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
