Population Health Nurse (RN or LPN)

Well Care Community Health, Inc.; Austin (IN); On-site; USD 34,440,000 - 48,216,000; Full time

Benefits offered by this job

Paid Vacation

Sick days

Personal days and 12 Major Holidays

Job summary

Well Care Community Health, Inc. seeks a Population Health Nurse to lead our chronic-disease hub.

You will translate registry and RPM data into outreach and interventions, develop nursing and RPM workflows, and coordinate the clinical team to deliver proactive, evidence-based care within licensed scope. You will oversee RPM readings, support the Case Manager and CHW, and partner with providers to address high-risk patients.

Qualifications

• Graduate of an accredited practical-nursing or registered-nursing program.
• Current, unrestricted Indiana RN or LPN license in good standing.
• Minimum of two years of clinical nursing experience; ambulatory care, primary care, chronic-disease management, care coordination, population health, public health, or comparable experience preferred.
• Experience with RPM, chronic care management, value-based care, clinical registries and/or EHR-supported care management preferred.
• Current CPR certification or ability to obtain and maintain certification within WCCH timeframe.

Responsibilities

• Assist in developing and managing a chronic-disease population health hub.
• Use registries and EHR data to identify patients needing preventive services or chronic-disease management.
• Develop and maintain RPM workflows, criteria, monitoring, and escalation pathways.
• Provide clinical oversight to RPM and escalate to providers as needed.
• Coordinate Case Manager support for RPM enrollment, onboarding, adherence outreach, and follow-up.
• Lead interdisciplinary population health huddles and coordinate work among staff.
• Provide nursing assessment and individualized care planning within scope and protocols.
• Follow up on abnormal results, medication concerns, hospital transitions, and high-priority care gaps.
• Collaborate with providers and pharmacy on medication adherence and plan implementation.
• Address social determinants of health and coordinate warm handoffs to CHW for navigation.
• Collaborate with hospitals and regional partners to strengthen referral and information-sharing pathways.
• Develop community-based and telehealth workflows that expand access while ensuring safety and privacy.
• Validate data quality and track clinical quality measures and program performance.
• Maintain accurate documentation in EHR and RPM platforms.

Skills

Population health

Care coordination

Nursing assessment

Clinical escalation

CPR certification

Education

Practical Nursing or Registered Nursing program

Indiana RN or LPN license

CPR certification

Job description

Principal Function

The Population Health Nurse serves as a clinical lead for WCCH's chronic-disease population health hub. The nurse translates registry, care-gap, utilization, and Remote Patient Monitoring (RPM) data into clinically appropriate outreach and intervention; develops and maintaining nursing and RPM workflows, coordinates the clinical work of the Case Manager, Community Health Worker (CHW), providers, pharmacy, informatics, and other staff, and helps ensure that patients with complex chronic conditions receive proactive, evidence-based, coordinated care. The nurse provides nursing assessment, education, clinical escalation, and quality oversight within the individual's licensed scope and WCCH clinical policies, while partnering with the Case Manager and CHW so clinical needs and nonclinical barriers are addressed by the appropriate team member.

Essential Duties and Responsibilities

• 1. Assist in the development, implementation, and ongoing management of a chronic-disease population health hub focused on diabetes, hypertension, cardiovascular disease, obesity, tobacco-related illness, and other high-risk conditions.
• 2. Use population health registries, risk-stratification tools, utilization information, and electronic health records (EHR) data to identify patients requiring preventive services, chronic-disease management, nurse follow-up, or targeted intervention.
• 3. Develop and maintain clinical RPM workflows, including patient-selection criteria, consent, monitoring frequency, alert thresholds, escalation pathways, documentation requirements, emergency instructions, and coverage expectations.
• 4. Provide clinical oversight to RPM by reviewing escalated readings and trends, completing nursing assessment and intervention within license scope and promptly involving the appropriate provider when clinical decision-making or treatment changes are needed.
• 5. Direct and coordinate the Case Manager's support of RPM enrollment, device onboarding, adherence outreach, routine dashboard workflow, and follow-up, while maintaining clear nursing and provider escalation pathways.
• 6. Lead interdisciplinary population health huddles and coordinate work among the Case Manager, CHW, providers, clinical pharmacy, informatics, laboratory, radiology, Street Medicine (RN), transportation, medication-access and other staff.
• 7. Provide nursing assessment, individualized clinical care planning, patient education, and chronic-disease self-management support within licensed scope and established protocols.
• 8. Conduct or coordinate timely clinical follow-up for abnormal results, medication concerns, hospital or emergency-department transitions, worsening symptoms, and high-priority care gaps.
• 9. Collaborate with providers and pharmacy staff on medication adherence, reconciliation, treatment plan implementation, and clinical escalation high-risk patients.
• 10. Identify social determinants of health and other practical barriers affecting the clinical plan; make a warm handoff to the CHW for community navigation while maintaining responsibility for appropriate clinical follow-up.
• 11. Collaborate with hospitals, specialists, health departments, behavioral health organizations, and other regional clinical partners to strengthen referral, transition-of-care, escalation, and information-sharing pathways.
• 12. Assist in developing community-based, mobile, and telehealth-enabled clinical workflows that expand access while maintaining safety, privacy, documentation, and continuity standards.
• 13. Validate clinical definitions and data quality with informatics; track and report clinical quality measures, patient outcomes, RPM activity and response, care-gap closure, referral completion, and program performance.
• 14. Maintain accurate, timely, and complete documentation in the EHR, RPM platform, and other required systems in accordance with organizational policies and regulatory requirements.
• 15. Participate in quality improvement, protocol review, staff training, and continuing education related to chronic-disease management, RPM, population health, value-based care, and regulatory requirements.

Supervisory Responsibilities

This job has no formal personnel-supervision responsibilities unless specifically assigned. This position provides clinical workflow direction and day-to-day coordination to Case Managers and CHW's with WCCH policy and the incumbent's licensed scope.

Education and/or Experience

• Graduate of an accredited practical-nursing or registered-nursing program.
• Current, unrestricted Indiana Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in good standing.
• Minimum of two (2) years of clinical nursing experience required; ambulatory care, primary care, chronic-disease management, care coordination, population health, public health, or comparable experience preferred.
• Experience caring for patients with diabetes, hypertension, cardiovascular disease, obesity, tobacco-related illness, and other complex chronic conditions preferred.
• Knowledge of population health principles, quality measures, preventive-care guidelines, risk stratification, and care gap closure strategies preferred.
• Experience with RPM, chronic care management, value-based care, clinical registries and/or EHR-supported care management preferred.
• Ability to recognize clinically significant trends, complete nursing assessment and intervention within licensed scope and accelerate promptly to the appropriate provider.
• Demonstrated ability to coordinate interdisciplinary work, provide clinical workflow direction, and maintain clear delegation and escalation boundaries.
• Experience addressing social determinants of health through team-based care and warm handoff to CHW's or community-resource staff preferred.
• Current CPR certification or ability to obtain and maintain certification within the WCCH required timeframe.

LPN at $25.00 RN at $35.00

Hours 8 am - 5 pm Monday-Friday

Wages are negotiable

Benefits

• Paid Vacation
• Sick days
• Personal days and 12 Major Holidays