Population Health Nurse(LPN/RN)

Good Samaritan•Vincennes, IN

About The Position

The Population Health Nurse promotes health and prevents disease in communities by helping patients identify symptoms early and addressing health risks proactively. The role assesses patient and community health needs, develops personalized intervention and care plans, monitors patient vital signs through internet-connected devices and an information platform, and educates patients about disease-specific issues, symptom management, and healthy living. The nurse also teaches patients to use remote patient monitoring equipment and encourages consistent use of monitoring devices. The position coordinates population health services such as congestive heart failure and diabetes education, Medicare annual wellness services, transitional care, and community resources. It involves frequent patient outreach to manage chronic conditions, gathering and communicating information about symptoms, conditions, and medications to providers, supporting appointment scheduling and preparation, and coordinating with home care providers during transitions of care. The nurse documents in technology platforms and the EHR, maintains accurate patient records, runs monthly reports, assists with month-end billing, and follows CMS requirements for billing and clinical documentation.

Requirements

Active LPN license in Indiana.
Proficiency in Microsoft Office and Excel.
Strong communication skills and organization.
Ability to work independently and as part of a team.
Strong ethics and values.
Critical-thinking and problem-solving skills.

Nice To Haves

Home health experience.

Responsibilities

Assess health needs, identify health problems, and identify community trends.
Develop intervention plans to help patients improve their health and safety.
Monitor patient vital signs through internet-connected devices and an information platform, personalizing monitoring according to provider orders.
Educate and coach patients on disease-specific issues and ways to live healthier lives.
Evaluate care plans and use data to improve patient outcomes and quality of life.
Help providers and office staff improve patient communication and education, and assist with scheduling appointments as needed.
Coordinate population health services, including CHF education, diabetes education, Medicare annual wellness services, transitional care, and community services.
Educate patients about disease-specific information, remote patient monitoring equipment, and symptom management.
Gather accurate information about symptoms, report patient condition details, understand medications, and communicate and follow up with providers and patients.
Conduct frequent patient outreach to manage chronic conditions and develop personalized care plans; serve as a trusted resource for patients reporting changes in condition.
Document using technology platforms and the EHR.
Connect patients with resources, prepare them for medical appointments, and encourage compliance with monitoring devices.
Run monthly reports and assist with month-end billing; follow CMS guidelines and ensure clinical documentation meets CMS requirements.
Communicate with home care providers to support patient transitions of care.
Maintain patient records and ensure information is up to date.