Population Health RN - GSPN Quality & Care Coordination

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.).