The Population Health Nurse will work in collaboration with primary care providers and healthcare teams. Primary responsibilities will include identification of Medicare patients appropriate for Annual Wellness Visits and execute guided processes to complete the visit. They will effectively coordinate and manage high-risk chronically ill patients through Chronic Care management utilizing health coaching techniques to assist patients with self-management of their chronic diseases and lifestyle changes to mitigate health risk. This position may also be responsible for other programs to include Transitional Care Management, Advance Care Planning, Post-Acute Care Coordination, and Behavioral Health Integration.
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