Registered Nurse - SCC Population Health / ACO

Job Title

Population Health / ACO Registered Nurse (RN)

Department

Population Health / ACO

Full Time/PRN

Full Time

Job Summary

The Population Health/ACO RN manages and improves health outcomes for patient populations through care coordination, evidence-based interventions, chronic disease management, preventive care, and patient engagement within a value-based care environment.

Minimum Qualifications

• Current and valid Registered Nurse (RN) license.
• Minimum of 2 years of clinical nursing experience, preferably in population health, case management, or care coordination.
• Strong knowledge of chronic disease management and preventive care principles.
• Familiarity with EHR systems and healthcare analytics tools.
• Excellent communication and interpersonal skills.

Preferred Qualifications

• Certification in Case Management (CCM) or Population Health Nursing.
• Experience working within an ACO or value-based care environment.
• Background in community health nursing or public health.
• Proficiency in motivational interviewing and patient engagement techniques .
• Advanced training in quality improvement methodologies and healthcare regulations.

Essential Duties & Responsibilities

• Conduct comprehensive patient assessments to identify health risks and care needs.
• Develop, implement, and monitor individualized care plans.
• Coordinate care transitions and follow-up activities to reduce avoidable readmissions.
• Utilize population health data to identify trends, care gaps, and intervention opportunities.
• Provide patient education and support for chronic disease self-management.
• Serve as a liaison between patients, families, and healthcare teams.
• Participate in quality improvement initiatives and support CMS and ACO performance metrics.
• Document patient interactions, care plans, and outcomes in the EHR.
• Perform additional duties as assigned by leadership.

Professional Responsibilities

• Apply clinical expertise and critical thinking to patient care planning.
• Collaborate effectively with multidisciplinary healthcare teams.
• Utilize data analytics and population health tools to improve outcomes.
• Promote preventive care and address social determinants of health.
• Support organizational quality, compliance, and value-based care initiatives.

Physical Requirements

• Ability to sit, stand, walk, bend, and perform patient assessments throughout the workday.
• Frequent use of computer systems, telephones, and electronic documentation tools.
• Ability to communicate effectively with patients, families, and healthcare professionals.

All candidates must be able to perform the essential functions of this position. The Americans with Disabilities Act (ADA) requires that reasonable accommodations be made for qualified individuals to help perform the essential functions of the position.

South Central Regional Medical Center is an equal opportunity employer and does not discriminate based on race, color, religion, sex, gender, national origin, age, disability, or genetic information.