Population Health RN

Population Health Nurse

The Population Health Nurse will work in collaboration with primary care providers and healthcare teams. Primary responsibilities will include the following:

• Identification of Medicare patients appropriate for Annual Wellness Visits & execute guided processes to complete the visit.
• Effectively coordinate & manage high-risk chronically ill patients through Chronic Care Management & Remote Patient Monitoring utilizing health coaching techniques to assist patients with self-management of their chronic diseases & lifestyle changes to mitigate health risk.
• Initiate Transitional Care Management coordinating efforts with post-acute providers (Home Health, PCP, Pharmacy, SNF etc.).

Essential Job Duties:

1. Attend and actively participate in all ACO population health related trainings and meetings including advanced health coach certification, regional workshops, webinars, roadmap and cohort calls, and one-on-one meetings, as needed
2. Works collaboratively with the ACO team to develop a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the provider; post reminders to secure that all co-morbidities are discussed and documented during AWV
3. Attend and actively participate in all Value Based Contract meetings, trainings & patient outreach
4. Stratify patient population according to risk score. Effectively and efficiently manage patients with multiple chronic diseases; Identify patients appropriate for Chronic Care Management (CCM). In collaboration with the PCP, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to care plan and progress toward goals and facilitate changes as needed.
5. Ensure sharing of positive patient stories or compliments involving care team efforts
6. Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, annual wellness visit scheduling, transition of care follow-up calls/visits, CCM encounters, navigate care for patients enrolled in RPM
7. CMA oversight as directed by Quality & Care Coordination Manager

Secondary Job Duties That May be Reassigned:

1. Perform other related duties as directed by Quality & Care Coordination Manager & Executive Director, Good Samaritan Physician Network

Job Specifications:

• Current licensure as a Registered Nurse
• Minimum of five years of clinical experience required, with at least two years in a physician/group practice or other ambulatory or outpatient setting
• Previous Care Coordination, Case Management, Home Health or Behavior Health experience preferred

About Us: For more than 115 years, Good Samaritan has been dedicated to not only providing trusted, industry-leading health care, but to fill a vital role in southwest Indiana and southwest Illinois. Our hospital continues to adhere to the compassionate principles our facility was founded on and further our commitments to our patients, our staff, and the communities we serve. Good Samaritan is well recognized for its commitment to excellence as a 4-time designated Magnet® facility, TJC Primary Stroke Center, and a Level III Trauma Center. We would love to welcome you to our Good Samaritan family.

About the Team: Thank you for your interest in employment at Good Samaritan Hospital. Please provide all information requested to assure that all your qualifications are fairly considered for current or future vacancies. Your application will remain in our active files for six months. After six months, re-application is necessary. The submission of this application does not automatically result in an employment interview or job offer. EQUAL EMPLOYMENT OPPORTUNITY POLICY Good Samaritan Hospital is an equal opportunity employer. It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability, national origin, color, or any other classification in accordance with federal state and local statements, regulations, and ordinances.

Job Info: Job Identification 21956, Job Category Registered Nurse, Posting Date 04/22/2026, 01:20 PM, Degree Level Bachelor's Degree, Job Schedule Full time, Locations 520 S 7th St, Vincennes, IN, 47591, US