Registered Nurse (RN) - Medicare Wellness and Care Coordination

Moab Regional Hospital • Moab, UT

65d • $31 - $45 • Hybrid

About The Position

The Registered Nurse (RN) serves as a key clinical professional within the Population Health and Care Coordination teams, responsible for optimizing patient outcomes across the Medicare population. This role encompasses conducting Annual Wellness Visits (AWVs), performing preventive health screenings, executing Hierarchical Condition Category (HCC) gap analyses with appropriate closure in documentation, and supporting patients through the full continuum of care—including Transitions of Care and Chronic Care Management programs. The RN collaborates closely with providers, Case Management, and Social Work to enhance the quality, safety, and experience of care for both patients and providers.

Requirements

• Current, active, and unrestricted Registered Nurse (RN) license in Utah.
• Minimum of three (3) years of recent clinical experience, with emphasis on primary care, population health, case management, or care coordination.
• Demonstrated knowledge of Medicare programs, including Annual Wellness Visits, HCC coding, and chronic/transition care processes.
• Exceptional communication, assessment, and problem-solving skills.
• Proficiency with EHR systems and data reporting tools.
• Commitment to patient-centered care and interprofessional collaboration.

Nice To Haves

• Bachelor of Science in Nursing (BSN) preferred.

Responsibilities

• Conduct comprehensive Medicare Annual Wellness Visits in alignment with Centers for Medicare & Medicaid Services (CMS) guidelines, including risk assessment, preventive screening, and individualized care planning.
• Identify, analyze, and close HCC documentation gaps to support accurate coding and appropriate risk adjustment.
• Assist in coordinating and managing patients enrolled in Chronic Care Management programs, promoting adherence to care plans, and optimizing clinical outcomes.
• Facilitate Transitions of Care following hospitalizations or emergency visits, ensuring timely follow-up, medication reconciliation, and continuity of services.
• Collaborate with Case Management, Social Work, and primary care teams to address medical, behavioral, and social determinants of health that influence patient well-being.
• Provide patient education on preventive care, chronic disease management, and resource utilization to encourage engagement and self-management.
• Monitor population health metrics, maintain accurate and compliant documentation within the electronic health record (EHR), and support data-driven performance improvement initiatives.
• Uphold all standards related to Medicare documentation, quality reporting, and regulatory compliance.

Benefits

• Wide range of benefits, including:
• Medical Insurance
• Mental health coverage for entire family
• Retirement 403b
• Paid time off
• Collaborative and supportive workplace
• Professional growth opportunities including continuing education, trainings, and more!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level