RN ANNUAL WELLNESS VISIT NURSE - SCC POPULATION HEALTH / ACO

South Central Regional Medical Center • Laurel, MS

10d • Onsite

About The Position

Provides nursing care within the Population Health / ACO program, focusing on Annual Wellness Visits (AWVs) for Medicare and Medicare Advantage patients. Acts as patient advocate, supports preventive care initiatives, and facilitates communication between patients, providers, and the interdisciplinary team to improve outcomes and close care gaps.

Requirements

• Current RN license by the Mississippi Board of Nursing
• Minimum of two (2) years clinical nursing experience
• Must be able to read, write, and understand verbal and written communication
• Strong organizational, communication, and time management skills

Nice To Haves

• Experience in population health, primary care, or ACO environment
• Familiarity with Medicare Annual Wellness Visit requirements and quality metrics
• Experience with electronic health records (Epic preferred)
• Certification in Population Health or Case Management preferred

Responsibilities

• Conduct Annual Wellness Visits including health risk assessments and screenings
• Identify eligible Medicare patients and coordinate AWV completion
• Develop individualized care plans based on patient needs and clinical guidelines
• Review and address care gaps and assist with closing quality measures
• Document all patient interactions accurately in the electronic health record
• Educate patients on disease prevention and self-management strategies
• Collaborate with physicians and care team members for coordinated care
• Monitor patient populations and support outreach initiatives
• Assist with patient messages, prescription refills, and other clinical tasks as needed
• Maintain compliance with ACO, CMS, and organizational standards
• Represent the organization professionally
• Maintain patient, team member, and employer confidentiality (HIPAA compliance)
• Promote safety, infection control, and quality improvement
• Maintain competency and adhere to policies
• Demonstrate teamwork, communication, and reliability

What This Job Offers

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