Population Health Nurse: Medicare Wellness & Coordination

Family Health Center – Southwest Indiana; Vincennes (IN); On-site; USD 65,000 - 90,000; Full time

Job summary

Family Health Center – Southwest Indiana is seeking a Population Health Nurse to coordinate Medicare Annual Wellness Visits (MAW), Chronic Care Management (CCM), and value-based care initiatives. You will identify eligible patients, conduct RN-led wellness visits, and develop patient-centered care plans to improve outcomes.

The role requires strong care coordination across primary care teams, accurate documentation in Epic, and ongoing quality improvement to support ACO programs and patient

Qualifications

• Graduate of an accredited registered nursing program.
• Current Basic Life Support (BLS) certification.
• Current, unrestricted Indiana RN license required.

Responsibilities

• Coordinate Medicare MAW and CCM activities and support ACO initiatives.
• Conduct RN-led wellness visits and develop patient-centered care plans.
• Coordinate referrals, follow-up, and transitions with care teams and community resources.
• Maintain accurate documentation in Epic and ensure quality improvement activities are supported.

Skills

Clinical assessment

Critical thinking

Patient education

Care coordination

Communication

EHR proficiency

Education

Registered Nurse license (Indiana)

BLS certification

Tools

Epic EHR

Job description

Family Health Center – Southwest Indiana is seeking a Population Health Nurse to coordinate Medicare Annual Wellness Visits (MAW), Chronic Care Management (CCM), and value-based care initiatives. You will identify eligible patients, conduct RN-led wellness visits, and develop patient-centered care plans to improve outcomes.

The role requires strong care coordination across primary care teams, accurate documentation in Epic, and ongoing quality improvement to support ACO programs and patient