Population Health Nurse

Population Health Nurse

Jordan Valley Health (JVH) is a mission-driven organization dedicated to improving the health of individuals and families in underserved communities. We provide comprehensive healthcare services including primary medical, dental, vision, and behavioral health. Our mission is simple: Improve our community's health through access and relationships. By working collaboratively with partners and continually innovating, JVH strives to be a leader in providing essential healthcare for the underserved, ensuring everyone in our community has access to quality healthcare.

The Population Health Nurse is responsible for conducting Annual Wellness Visits (AWVs) in coordination with the Population Health Department. This position supports the organization's value-based care and incentive program goals by delivering comprehensive wellness assessments, identifying preventive care needs, closing care gaps, and promoting patient engagement in chronic disease management. The nurse will collaborate closely with providers, care teams, and the payer programs staff to ensure alignment with Medicare guidelines and payer incentive benchmarks. The ideal candidate understands healthcare quality measures and has a strong ability to communicate across clinical, administrative, and payer audiences to ensure the overall wellbeing of our patient population through collaborative engagement.

Key Responsibilities:

• Perform annual wellness visits (initial and subsequent) in accordance with guidelines, including documentation of health risk assessments, screenings, and preventive services.
• Collaborate with the Population Health Department to identify eligible patients through outreach lists and reporting tools.
• Conduct pre-visit planning and patient outreach to schedule AWVs and support timely completion of services.
• Document all visits thoroughly in the electronic health record (EHR), ensuring accurate coding and compliance with payer requirements.
• Collaborate with clinical staff trainer to ensure documentation is appropriate for closure of care gaps related to value-based incentives.
• Educate patients on preventive care services, chronic disease self-management, and care coordination resources.
• Identify and communicate care gaps to providers and appropriate care team members to support follow-up actions.
• Assist in data tracking and reporting to support payer quality initiatives and incentive programs.
• Participate in team meetings, trainings, and process improvement initiatives related to Medicare wellness and value-based care.
• Maintain up-to-date knowledge of Medicare wellness visit requirements, CMS guidelines, and payer incentive structures.
• Support compliance with UDS, HRSA, and other regulatory documentation standards.
• All other duties as assigned.

Benefits Overview:

• Medical and Prescription Drug Coverage: Three comprehensive plan options (Buy-up, Base, and High Deductible) through UnitedHealthcare's Choice Plus network, covering various deductibles and out-of-pocket limits. Includes access to telemedicine services via Teladoc.
• Health Savings Account (HSA): Available for employees in the High Deductible Plan with employer contributions and tax advantages.
• Flexible Spending Account (FSA): Options for both healthcare and dependent care FSAs, allowing pre-tax contributions for qualified expenses.
• Dental and Vision Coverage: Dental insurance through Cigna's DPPO network and vision coverage through EyeMed's Insight network.
• Retirement Plan: Pre-tax and Roth 403(b) retirement plans with a 5% employer match starting after 30 days of employment.
• Life and Disability Insurance: Basic Life and AD&D insurance provided at no cost, with the option to purchase additional coverage. Long-term and short-term disability insurance are also available.
• Employee Assistance Program (EAP): Free confidential support for personal and professional challenges, including counseling and crisis intervention.
• Additional Voluntary Benefits: Options for critical illness, accident, hospital care, and pet insurance through MetLife.
• Pay on Demand Available

• Holidays: Nine paid holidays per year.

Health Requirements:

All employees are required to provide proof of vaccination for Flu, Hepatitis B and Tuberculosis (TB) as part of our commitment to maintaining a safe and healthy workplace.

Application Process:

Interested applicants should submit a resume and cover letter through the JVH career portal at Careers & Education - Jordan Valley. Applications will be accepted on a rolling basis until the position is filled.

Jordan Valley Health is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

Required Qualifications:

• Completion of an accredited Practical Nursing program; must hold a current LPN license
• Associate's Degree in Nursing (ADN) required
• Current, unrestricted license as an LPN or RN in the state of Missouri
• Basic Life Support (BLS) required, must obtain within first 90 days of employment
• Minimum 1- 2 years of clinical experience in primary care, geriatrics, or community health
• Experience in a Federally Qualified Health Center (FQHC) or safety-net healthcare environment.
• Familiarity with UDS, HRSA, NCQA PCMH, and state Medicaid incentive structures.

Preferred Qualifications:

• Bachelor of Science in Nursing (BSN) preferred

Jordan Valley Community Health Center