Population Health Nurse

Job Description

Job Description

Position Overview

The Population Health Nurse is an integral member of PBACO’s Clinical Department, supporting provider-facing population health and clinical initiatives designed to improve patient outcomes across the ACO network. This role serves as a clinical liaison between PBACO and its network of primary care providers, helping translate population health data into actionable strategies that improve patient outcomes, quality performance, close care gaps, and support evidence-based care.

Responsibilities include provider education, clinical program implementation, practice support, data-driven performance improvement, and patient engagement activities as organizational priorities evolve. The position collaborates closely with physicians, office staff, pharmacists, nurse practitioners, and other members of the clinical team to advance PBACO's value-based care initiatives.

This position requires approximately 30-40% local travel to meet with providers on-site across PBACO’s network.

Key Responsibilities

• Serve as a clinical liaison between PBACO’s clinical team and network primary care providers (PCPs), fostering collaborative relationships and ongoing communication.

• Conduct on-site and virtual provider education and consultation to support ACO initiatives, review clinical initiatives, and promote adoption of population health workflows and technology.

• Partner with physicians, care teams, and office staff to improve chronic disease management, close care gaps, and support evidence-based clinical practices.

• Translate population health data into actionable recommendations that improve quality metrics, patient outcomes, and practice performance.

• Educate providers and staff on ACO programs, clinical initiatives, and population health tools.

• Support the implementation, coordination, and evaluation of clinical programs and population health initiatives.

• Support patient engagement and care coordination activities as assigned to improve health outcomes.

• Assist with pharmacy-related initiatives, such as medication adherence outreach and refill follow-up programs, as needed to support patient care.

• Assist in the development of educational tools, workflows, and communication materials that support clinical programs and patient engagement.

• Monitor program outcomes, maintain accurate documentation, and assist with reporting to measure the effectiveness of clinical initiatives.

• Participate in quality improvement activities, special projects, and other initiatives that support PBACO’s value-based care goals.

Qualifications & Experience

• Active RN license required; Florida licensure and Compact RN licensure preferred

• 2+ years of experience in a healthcare setting; case management experience strongly preferred.

• Prior experience in population health, an ACO, value-based care, or managed care environment is a significant plus.

• Demonstrated ability to build and maintain collaborative relationships with physicians and clinical office staff.

• Knowledge of healthcare delivery systems across outpatient, hospital, and post-acute settings.

• Comfortable conducting professional, clinical conversations with both providers and patients over the phone, virtually and in person.

• Strong organizational, communication, and independent problem-solving skills.

· Proficiency in EMR systems and Microsoft Office Suite (Word, Excel, PowerPoint),

· Advanced skills with Spreadsheets / Report Writing / PowerPoint / Word/ Excel.

• Valid, unrestricted driver’s license; ability and willingness to travel locally approximately 30-40% of the time.

• Ability to work independently and as a collaborative member of the clinical team.

• Knowledge of legal and ethical considerations related to patient information (HIPAA).

Core Competencies

• Physician & Provider Relations — comfortable presenting data and recommendations to clinical audiences

• Care Coordination & Case Management — skilled at managing complex patients needs and implementing care plans

• Organization & Planning — manages multiple priorities and deadlines independently

• Communication — articulate, professional, and effective in both written and verbal interactions

• Clinical Judgment — ability to recognize risk and escalate appropriately

• Adaptability — thrives in a growing department with evolving priorities

• Technology Proficiency — EMR, Microsoft Office, point of care tools, reporting tools

• Integrity — adheres to HIPAA, confidentiality, and all applicable compliance standards