population health nurse

Galileo

<div>
 <p>
  <strong>
   About Us
  </strong>
 </p>
 <p>
  <span>
   Galileo is a team-based medical practice working to improve the quality and affordability of health care for all. Operating across 50 states, Galileo offers high-touch, data-driven, multi-specialty, longitudinal care to diverse and complex patients&mdash;on the phone, in the home, and everywhere in between. Regional and national health plans, employers, and Fortune 500 organizations trust Galileo as the leading solution to improve population health. Founded by Dr. Tom X. Lee, the healthcare pioneer behind One Medical and Epocrates, Galileo is a team of leading innovators from healthcare, technology, and human-centered design. Our mission is to apply that talent and scientific thinking to
  </span>
  <span>
   transform society by solving our largest, toughest healthcare problems, while at the same time bringing patient and provider closer.
  </span>
 </p>
 <p>
  <strong>
   About the Role:
  </strong>
 </p>
 <p>
  Are you a Registered Nurse who thrives on connecting with patients and making a real difference in their health outcomes? Do you want to leave behind rigid, cookie-cutter systems and join a dynamic, patient-centered organization that values your creativity and clinical expertise? If you are passionate about improving patient outcomes and enjoy making meaningful connections, we want you to be part of our team at Galileo!
 </p>
 <p>
  At Galileo, we&rsquo;re transforming healthcare by delivering personalized, comprehensive care to those who need it most&mdash;underserved patients and patients with complex medical needs. Our focus is on patient engagement and outcomes, and we&rsquo;re looking for someone just like you to join our growing team of healthcare heroes.
 </p>
 <p>
  This is a remote, full-time position at 40 hours/week. We're currently hiring for a schedule of Monday-Friday from 10am-6:30pm ET, with one weekend per month.
 </p>
 <p>
  <strong>
   Here&rsquo;s what you&rsquo;ll do:
  </strong>
 </p>
 <ul>
  <li>
   Telephonic outreach, including cold calls, to patients for post discharge assessments of clinical symptoms, barriers to medication adherence, safety concerns, social needs
  </li>
  <li>
   Educate and coordinate preventative health screenings
  </li>
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   Perform chronic disease management and medication adherence education
  </li>
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   Navigate conversations with patients seeking insight on Galileo&rsquo;s care model
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  <li>
   Facilitate the coordination of care between health care services, including hospital/ED care, pharmacies and community providers to improve patient outcomes
  </li>
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   Develop an understanding of various health plan contracts / goals, Galileo markets, and needs of various patient populations
  </li>
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   Be accountable to performance targets as an individual contributor
  </li>
  <li>
   Collaborate internally with Engagement and Population Health leadership to improve population outcomes
  </li>
 </ul>
 <p>
  <strong>
   About You:
  </strong>
 </p>
 <p>
  You&rsquo;re a &ldquo;people person&rdquo;.&nbsp; You love to connect with others and have an innate ability to build rapport and quickly engage with new patients. Your curious nature and creativity comes through in conversations with others. You&rsquo;re looking for a new environment where your natural ability can shine and you&rsquo;re given the ability to thrive.
 </p>
 <p>
  We look for passionate Registered Nurses who are invested in solving complex problems that impact millions of lives and are excited about fixing what&rsquo;s broken to improve care quality and health outcomes for everyone.&nbsp; We believe in a culture that fosters teamwork, excellence, and sound decision-making&mdash;one that is based on mutual respect and trust.
 </p>
 <p>
  <strong>
   We would love to hear from you if you have the following or equivalent experience:
  </strong>
 </p>
 <ul>
  <li>
   2+ years of experience in case management in insurance organizations or VBC health care startups OR as a primary care RN with population health experience
  </li>
  <li>
   Engaging with Medicare and Medicaid populations with complex chronic conditions
  </li>
  <li>
   Nurse Licensure Compact (NLC) required
  </li>
  <li>
   Active RN license(s) in NY, NV, MI, MN, OR, CA, MA, CT and/or IL a plus
  </li>
  <li>
   Ability to leverage your motivational interviewing skills to encourage patients to make behavioral changes
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  <li>
   Excellent written and verbal communication skills
  </li>
  <li>
   Familiarity with Population Health and HEDIS quality gaps in care preferred
  </li>
  <li>
   Well versed with operating in an Mac iOS and Google Suite technology environment&nbsp;
  </li>
 </ul>
 <p>
  <strong>
   Physical Requirements:
  </strong>
 </p>
 <p>
  Employee must be able to meet the following requirements with or without a reasonable accommodation: This is primarily a sedentary position. Physical requirements may include lifting up to 10 pounds, manual dexterity, near/far visual acuity, keyboarding, the ability to hear, understand, and distinguish speech, sitting, standing, walking, and screen usage 8 or more hours per day.
 </p>
 <p>
  <strong>
   Compensation:
  </strong>
 </p>
 <p>
  $46/hr (regular hours) and $55/hr (premium hours)
 </p>
 <p>
  <strong>
   Benefits:
  </strong>
 </p>
 <ul>
  <li>
   Medical / Dental / Vision insurance
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  <li>
   Flexible Spending Account
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   Health Savings Account + match
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   Company paid STD/LTD, AD&amp;D, and Life insurance
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  <li>
   Paid Family Leave
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   Paid Time Off
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  <li>
   401K + match
  </li>
 </ul>
 <p>
  <strong>
   How We Hire
  </strong>
 </p>
 <p>
  Galileo Health is an equal-opportunity employer and welcomes applicants from all backgrounds.
 </p>
 <p>
  We have recently become aware of the fraudulent use of our name on job postings and via recruiting emails that are illegitimate and not in any way associated with us. We will never ask you to provide sensitive personal information as part of the recruiting process, such as your social security number; send you any unsolicited job offers or employment contracts; require any fees, payments or access to any financial accounts; and/or conduct text-only interviews. If you suspect you are being scammed or have been scammed online, you may report the crime to the Federal Bureau of Investigation&nbsp;and obtain more information regarding online scams at the&nbsp;Federal Trade Commission.
 </p>
</div>


Population Health Registered Nurse

Whittier Street Health Center

<p><b>Compensation &amp; Benefits Include:</b></p><ul><li>$42.00&ndash;$48.00 hourly</li><li>Health, dental, and vision insurance</li><li>Employer-funded pension &amp; life insurance</li><li>403(b) retirement plan</li><li>Paid time off and holidays</li><li>CME reimbursement and licensure support</li></ul><p><b>The Opportunity:</b></p><p>Whittier Street Health Center is seeking a full-time Clinical Programs Nurse to join our Center for Health Equity Research. In this role, you will support the coordination and delivery of clinical programs, working closely with care teams and patients to manage chronic conditions, support preventive initiatives, and contribute to research-related activities.</p><p>The Center for Health Equity Research advances equitable health outcomes through community-centered care and clinical research. By integrating preventive care, specialty clinics, and evidence-based interventions, the Center works to address chronic disease disparities, improve access, and enhance long-term outcomes for the communities we serve.</p><p><b>Key Responsibilities:</b></p><ul><li>Coordinate clinical program activities including Remote Patient Monitoring, specialty clinics, and prevention initiatives</li><li>Identify and engage eligible patients through outreach, referrals, and registry review</li><li>Provide patient education on chronic disease management, screening, and follow-up care</li><li>Support clinical research activities including recruitment, enrollment, and data collection</li><li>Ensure compliance with IRB protocols, regulatory standards, and Good Clinical Practice (GCP)</li><li>Coordinate referrals and support navigation to specialty and supportive services</li><li>Document patient interactions and maintain accurate clinical and research data</li><li>Collaborate with care teams to improve workflows, program outcomes, and quality initiatives</li></ul><p><b>Qualifications:</b></p><ul><li>Licensed Registered Nurse in the Commonwealth of Massachusetts</li><li>3&ndash;5 years of RN experience, preferably in primary care, population health, or research settings</li><li>Experience with phlebotomy required</li><li>Experience with EMR systems required; EPIC strongly preferred</li><li>Proficiency in Microsoft Office and standard computer applications</li><li>Strong communication, organizational, and time-management skills</li><li>Ability to work effectively in multidisciplinary and multicultural environments</li><li>Current Basic Life Support (BLS) certification</li></ul><p><b>Join Our Team!</b></p><p>Whittier Street Health Center is dedicated to advancing health equity and delivering high-quality, culturally responsive care. We are committed to building a diverse, inclusive workplace where every team member contributes to improving the health and well-being of our community. If you&rsquo;re ready to make a meaningful impact, we&rsquo;d love to hear from you.</p><p>#indlp</p><p>Pay: $42.00 - $48.00 per hour</p><p>Benefits:</p><ul><li>403(b)</li><li>Continuing education credits</li><li>Dental insurance</li><li>Disability insurance</li><li>Employee assistance program</li><li>Flexible spending account</li><li>Health insurance</li><li>Health savings account</li><li>Life insurance</li><li>Paid time off</li><li>Referral program</li><li>Retirement plan</li><li>Tuition reimbursement</li><li>Vision insurance</li></ul><p>Application Question(s):</p><ul><li>How many years of experience do you have working as a Registered Nurse?</li><li>Are you currently licensed as a Registered Nurse in Massachusetts?</li><li>Do you have experience performing phlebotomy?</li></ul><p>Ability to Commute:</p><ul><li>Boston, MA 02120 (Required)</li></ul><p>Work Location: In person</p>

Clinical Programs Nurse | Center for Health Equity Research | Boston

URBAN HEALTH PLAN, INC.

<div>
 <strong>
  Job Description
  <br/>
  <br/>
 </strong>
 <strong>
  Position Summary:
  <br/>
  <br/>
 </strong>
 The Bilingual English/Spanish Care Transitions Nurse (RN) is responsible for supporting patients during critical transitions of care, particularly following emergency room visits, hospital discharges, and specialty care episodes. This role ensures timely follow-up, medication reconciliation, care coordination, and patient education to reduce readmissions and prevent gaps in care.
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 <br/>
 The Care Transition Nurse works closely with primary care providers, specialists, care management teams, and community partners to ensure continuity of care and improve health outcomes for high-risk and medically complex patients.
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 This role supports the organization's population health, quality improvement, and value-based care initiatives by facilitating safe transitions and promoting patient engagement in ongoing care.
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 <br/>
 As part of the Virtual Care Center- this role is a fully remote position. Although remote, incumbents are required to engage in in person and Bronx-based service throughout training period, and throughout employment for trainings and meetings when requested. Required schedule included Monday through Friday 9am-6pm shift.
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 <strong>
  Minimum Qualifications
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  <br/>
 </strong>
 <ul>
  <li>
   Associates or Bachelors in Nursing is required.
  </li>
  <li>
   NYS Licensed Registered Nurse is required.
  </li>
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   Minimum of 2-5 years of clinical nursing experience is required in ambulatory care, community health, or related setting.
  </li>
  <li>
   Bilingual Spanish/English is required.
  </li>
  <li>
   Strong care coordination and patient communication skills
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   Knowledge of hospital discharge processes and transitional care management
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   Ability to identify clinical and social determinants of health impacting care
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   Proficiency in electronic health records and care documentation
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   Ability to work collaboratively across multidisciplinary teams
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  </li>
 </ul>
 <strong>
  Key Duties
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  <br/>
 </strong>
 <strong>
  Transitional Care Management &amp; Patient Follow-Up
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  <br/>
 </strong>
 <ul>
  <li>
   Conduct outreach to patients following hospital or emergency department discharge
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   Complete Transitional Care Management (TCM) workflows in accordance with CMS guidelines
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   Ensure patients receive timely follow-up appointments with primary care providers or specialists
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   Facilitate specialty care coordination by assisting patients in navigating referrals, scheduling appointments, and ensuring appropriate follow-up with specialty providers.
  </li>
  <li>
   Perform medication reconciliation and assess for medication adherence and safety concerns
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  <li>
   Identify and address barriers to care, including transportation, social needs, and access issues
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  <li>
   Perform medication reconciliation and assess for medication adherence and safety concerns
  </li>
  <li>
   Identify and address barriers to care, including transportation, social needs, and access issues
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   <br/>
  </li>
 </ul>
 <strong>
  Care Coordination &amp; Continuity of Care
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 </strong>
 <ul>
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   Coordinate care between hospital systems, primary care providers, specialists, and community resources.
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   Review discharge summaries and hospital documentation to ensure appropriate follow-up care
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   Facilitate referrals, diagnostic testing, and specialty appointments as needed
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   Support patients in understanding discharge instructions and treatment plans Ensure patients do not fall through gaps in care during transitions
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  </li>
 </ul>
 <strong>
  High-Risk Patient Management
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 </strong>
 <ul>
  <li>
   Identify high-risk patients based on clinical, social, and utilization risk factors
  </li>
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   Provide additional monitoring and outreach for patients at risk of readmission
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  <li>
   Collaborate with care managers, CHWs, behavioral health providers, and social services to address complex patient needs
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   <br/>
  </li>
 </ul>
 <strong>
  Patient Education &amp; Engagement
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 </strong>
 <ul>
  <li>
   Provide patient-centered education regarding diagnosis, medications, warning signs, and follow-up care
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   Promote patient self-management and adherence to treatment plans
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   Encourage ongoing engagement with primary care services
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   Address health literacy and cultural considerations to improve understanding and compliance
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   <br/>
  </li>
 </ul>
 <strong>
  Data Documentation &amp; Reporting
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 </strong>
 <ul>
  <li>
   Document patient encounters and care coordination activities in the EHR
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   Track outreach efforts, successful contacts, and follow-up outcomes
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   Support reporting for Transitional Care Management (TCM) billing and quality measures
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   Contribute to organizational reporting related to readmission reduction and care continuity
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  </li>
 </ul>
 <strong>
  Quality Improvement &amp; Population Health
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 </strong>
 <ul>
  <li>
   Participate in initiatives aimed at reducing avoidable hospitalizations and emergency room utilization
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   Identify patterns or barriers affecting successful transitions of care
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   Collaborate with leadership to improve workflows related to discharge follow-up and care coordination
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   Support quality improvement initiatives related to patient access and care continuity
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   <br/>
  </li>
 </ul>
 <strong>
  Collaboration &amp; Team Integration
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 </strong>
 <ul>
  <li>
   Work closely with providers, care management teams, call center staff, and telehealth teams to coordinate patient care
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   Communicate patient updates and concerns to primary care teams in a timely manner
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   Participate in multidisciplinary meetings focused on high-risk patient management and care planning
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   <br/>
  </li>
 </ul>
 <strong>
  Starting Compensation:
 </strong>
 Minimum $86,560 per year; Maximum $98,560 per year contingent on degree and years of nursing experience.
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 <strong>
  As a full time associate at Urban Health Plan, you'll enjoy:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Fully funded Health Insurance for you/ 73.5% funded Health Insurance for your family
  </li>
  <li>
   Dental, Vision, and Prescription Coverage
  </li>
  <li>
   401(k) Retirement Savings (including 3% annual employer contribution)
  </li>
  <li>
   Comprehensive time off including paid vacation, personal time, sick time, and paid holidays (including your birthday!)
  </li>
  <li>
   Flex Spending Accounts (Health care, Dependent Care, and Commuter Benefits)
  </li>
  <li>
   Entertainment Discount Programs
  </li>
  <li>
   Employee Assistant Program
  </li>
  <li>
   Eligibility to apply for Public Service Loan Forgiveness Program (PSLF)
  </li>
  <li>
   Fitness Discounts and Perks through our medical plan.
  </li>
  <li>
   $50,000 term life Insurance
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   <br/>
  </li>
 </ul>
 <strong>
  About Urban Health Plan
  <br/>
  <br/>
 </strong>
 At Urban Health Plan (UHP) our mission is to continuously improve the health of communities and the quality of life of the people we serve by providing affordable, comprehensive, quality, primary and specialty health care and by assuring the performance and advancement of innovative best practices. At UHP, our commitment to provide patient-centered, holistic, quality health care, is part of a tradition started by our founder, Dr. Richard Izquierdo, 50 years ago. That tradition continues today by promoting excellence in everything that we do.
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 <em>
  UHP is an equal opportunity employer. M/F/D/V. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex, sexual orientation, gender identity, gender expression, national origin/ancestry, citizenship status, disability, age, marital or family status, and military or veteran status.
  <br/>
  <br/>
 </em>
 Job Requirements
</div>


Care Transitions Nurse (RN)

ABILITIES FIRST

<div><p><b>PRIMARY PURPOSE OF JOB</b>:</p>
<p>
The Abilities First DD Health Home/ &ldquo;Steps Forward&rdquo; Nurse Care Manager (NCM) plays a pivotal role in managing the the population health needs and gaps in care of the DD Health Home population by adopting a whole-person approach that encompasses both physical and behavioral health aspects of individuals served in the DD Health Home program. The NCM will provide services reflecting the six core services of the DD HH program including care management, care coordination, health promotion, comprehensive transitional care, individual and family support, and referral to community and social support services.</p>
<p>
The NCM will work closely with the DD Health Home Directors, Physician Consultants or APRNs, and the Specialized Healthcare Consultants, as well as other members of the individual&rsquo;s health and care teams to assess current health needs, services, gaps in care and health assessment for each DD Health Home client assigned. The NCM will conduct health assessments, assist in developing and monitoring individual plan health goals and progress related to medical, and social determinants of health needs. The NCM is responsible for providing individual and population health education services. The NCM must provide a minimum of one core service for each assigned DD Health Home client per month. The NCM will utilize electronic health record systems to review, record health information and document health outcomes and services provided.</p>
<p><b>
This description may not include all duties, knowledge, skills, or abilities associated with this position.
</b></p><p><b>ESSENTIAL FUNCTIONS AND PERFORMANCE AREAS</b>:</p>
<ul><li>
Facilitate and participate in an organized, interdisciplinary team approach to care management for all assigned DD Health Home clients as well as the Abilities First DD Health Home overall population.</li><li>
The NCM will meet with individuals assigned to the Abilities First DD HH within the required timelines to explain to the individual the benefits and purpose of the DD HH program.</li><li>
The NCM must conduct a chart review within 30 days of enrollment of the individual into the DD HH program. In this process the NCM will become familiar with the clinical record and individual&rsquo;s history and identify and prioritize health issues which may exist and begin the health care assessment and health plan process.</li><li>
The NCM shall complete a Metabolic Syndrome (MBS) screening with individuals as needed and per the timelines and required frequency as mandated by the DD Health Home contract and provider manual. The DD HH NCM will coordinate with the individual&rsquo;s PCP to determine the recommended time frame for obtaining new lab values.</li><li>
The NCM must document services provided, clinical measures and data obtained, and reviews in each assigned individuals&rsquo; medical records; notes must, at a minimum, document the chart review occurred and be entered into the record within 72 hours of service.</li><li>
As part of comprehensive care management services, the DD HH NCM is responsible for completing standardized, comprehensive assessments of individuals&rsquo; health needs. The health information will be documented on a Health Screen form and entered into the appropriate electronic health record system/s.</li><li>
The DD HH NCM must conduct an annual face-to-face (video or in person) meeting with the individual and parent/guardian to review the health information, discuss healthcare concerns, and help translate health and wellness goals for inclusion in the individual&rsquo;s DD HH healthcare goals.</li><li>
The NCM must monitor and regularly follow up on patients' health progress, adjusting treatment plans as necessary.</li><li>
As part of Care Coordination, health promotion and family support services, the NCM will help develop an overall person-centered health plan for each individual, which coordinates and integrates all clinical and social determinants of health-related needs and services and facilitates the individuals&rsquo; participation in the ongoing revision of their DD HH healthcare goals.</li><li>
The NCM will encourage active individual involvement through appropriate linkages, referrals, coordination, and follow up to needed services and support.</li><li>
The NCM will document individual services in the individual&rsquo;s medical record including, but not limited to, comprehensive care management monitoring for care management gaps. Documentation must meet the DMH/MO HealthNet requirements.</li><li>
The NCM will utilize the DMH/DD identified system on a regular basis and are able to revise DD HH healthcare goals, as necessary.</li><li>
The NCM must perform timely medication reconciliation interventions and sign off on the medication reconciliation when complete, as mandated and defined in the DD Health Home contract and provider manual. A progress note must be entered in the individual record documenting the completion and results of the medication reconciliation. A transfer or hospital follow-up and medication reconciliation review must occur within 7 days for any DD HH enrollee that has been discharged from the hospital.</li><li>
The NCM will develop education to teach individuals how to manage their chronic illnesses and encourage healthy lifestyles.</li><li>
The NCM is responsible for overseeing the health trends of the entire population of individuals, following-up on identified trends impacting the health of the population, addressing high utilizers, participating in health education activities, including, as examples, topics on smoking cessation, disease prevention, and medication adherence.</li><li>
The NCM will coordinate care of DD HH participants enrolled in Managed Care Organizations (MCO) including keeping MCO apprised of individual&rsquo;s needs; follow up with the individual&rsquo;s interactions with the MCO during scheduled visits or phone calls; notify the MCO of individual&rsquo;s discharge from the DD HH, as applicable.</li><li>
The NCM will maintain relationships and coordinate communication with individuals&rsquo; primary care physician. Assist the enrollee in acquiring a primary care physician when needed.</li><li>
The NCM must demonstrate the ability to identify potential abuse and neglect situations and follow protocol according to all applicable regulatory requirements.</li><li>
The NCM must have the ability to bend, sit, stand, and stoop.</li><li>
The NCM must have the ability to establish effective working relationships with co-workers and the public.</li><li>
NCM may not exceed the maximum 1 FTE: 200 individuals served ratio. This includes staff filling these roles on a part-time basis.</li><li>
Other duties as assigned</li></ul>
<p><b>
WORK ENVIRONMENT</b>:
</p><p>The work environment described here is representative of those an employee encounters while performing the essential duties and responsibilities of this job. The work environment is fast-paced and result-oriented, which presents multiple demands with frequent interruptions, constantly shifting schedules and priorities and simultaneous deadlines requiring the employee to be flexible, organized and cooperative. This position has access to confidential information. This requires the employee to maintain a high level of knowledge in confidentiality, agency policy and procedure, and applicable laws.</p>
<p><b>
LEADERSHIP, ETHICS, AND PROFESSIONAL CONDUCT</b>:</p>
<p>
Abilities First employees are expected to model exemplary leadership at all times. This includes representing the agency in a positive, respectful, and professional manner through words, actions, and expressions. Employees are expected to communicate concerns, challenges, and differing perspectives through the established chain of command, using constructive, solution-focused, and professional language rather than judgmental or disparaging commentary. Abilities First expects staff to observe the highest ethical standards, maintain professional conduct above reproach and demonstrate unwavering integrity in all internal and external interactions.</p>
<p><b>
KNOWLEDGE, SKILLS, AND ABILITIES</b>:</p>
<ul><li>
Knowledge and experience teaching self-management</li><li>
Excellent telephone and interpersonal communication skills</li><li>
Ability to multi-task and prioritize, strong organizational skills</li><li>
Strong knowledge of medical terminology</li><li>
Strong knowledge of disease process/disease management and nursing care/body systems throughout the lifespan</li><li>
Computer experience required (Microsoft Office, Microsoft Teams)</li><li>
Electronic health record experience required</li></ul>
<p><b>
CORE COMPETENCIES</b>:
</p><p>Core competencies align with the Abilities First Core Values <b>&ndash; OATH</b></p>
<p><b>
One Team One Mission</b></p>
<ul><li><i>
Contributing to Team Success</i> &ndash; Actively participating as a member of a team to move the team toward the completion of goals.</li><li><i>
Engagement Readiness</i> &ndash; Demonstrating a willingness to commit to one&rsquo;s work and to invest one&rsquo;s time, talent and best efforts in accomplishing organizational goals.</li></ul>
<p><b>
Accountable, respectful service</b></p>
<ul><li><i>
Continuous Improvement</i> &ndash; Originating action to improve existing conditions and processes, identifying improvements opportunities, generating ideas, and implementing solutions.</li><li><i>
Quality Orientation</i> &ndash; Accomplishing tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.</li><li><i>
Technical/Professional Knowledge and Skills</i> &ndash; Having achieved a satisfactory level of technical and professional skill or knowledge in position-related area, keeping up with current developments and trends in area of expertise.</li></ul>
<p><b>
Transparent stewardship</b></p>
<ul><li><i>
Decision Making</i> &ndash; Identifying and understanding issues, problems, and opportunities; comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints, and probable consequences.</li><li><i>
Planning and Organizing</i> &ndash; Establishing courses of action for self and others to ensure that work is completed effectively.</li></ul>
<p><b>
Hold the rope</b></p>
<ul><li><i>
Adaptability</i> &ndash; Maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusting effectively to work within new work structures, processes, requirements, or cultures.</li><li><i>
Leadership Disposition</i> &ndash; Demonstrating the traits, inclinations, and dispositions that characterize successful leaders; exhibiting behavior styles that meet the demands of the leader role.</li></ul>
<p><b>
EDUCATION, TRAINING AND EXPERIENCE REQUIREMENTS</b>:</p>
<ul><li>
(1) Registered Nurse who has a current Missouri or compact RN license recognized by the Missouri State Board of Nursing as an RN OR (2) Licensed Practical Nurse who has a current Missouri or compact LPN license recognized by the Missouri State Board of Nursing as an LPN.</li><li>
At least one year of professional nursing experience required.</li><li>
Experience in the IDD field is preferred, but not required.</li></ul>
<p><b>
ADDITIONAL REQUIREMENTS</b>:</p>
<ul><li>
Must have a valid Missouri Driver&rsquo;s License, acceptable driving record and auto liability insurance that meets the requirements set by Abilities First.</li><li>
Must have secure and reliable high-speed internet in instance of working remotely.</li><li>
Must be able to pass a background screening.
</li></ul><p><b>PHYSICAL CONTEXT AND WORK ENVIRONMENT:</b></p>
<p><b>
Reasonable accommodations may be made to enable individuals with disabilities to perform essential job duties</b>.</p>
<div><div><div><b>
Physical Requirements</b><br>
</div><div><b> Percentage of Work Time Spent on Activity</b></div></div><br>
<div><div>
</div><div><b> 0-24%</b></div><div><b> 25-49%</b></div><div><b> 50-74%</b></div><div><b> 75-100%</b></div></div><br>
<div><div><b>
Seeing:</b> Must be able to see to read documents/reports and focus on computer for an extended period.</div><div></div><div> X</div></div><br>
<div><div><b>
Hearing:</b> Must be able to hear well enough to communicate with coworkers and general public.</div><div></div><div> X</div></div><br>
<div><div><b>
Sitting: </b>Must be able to sit for long periods of time.</div><div></div><div> X</div></div><br>
<div><div><b>
Standing/Walking:</b> Must be able to move about the work area.</div><div> X</div></div><br>
<div></div><div><div><b>
Climbing/Stooping/Kneeling:</b> Must be able to stoop or kneel to pick up items off the floor and filing in a bottom drawer file cabinet.</div><div> X</div></div><br>
<div></div><div><div><b>
Lifting/Pulling/Pushing</b>: Must be able to lift 20 pounds with or without reasonable assistance.</div><div> X</div></div><br>
<div></div><div><div><b>
Driving: </b>Must be able to drive locally for work-related assignments.<br>
</div><div> X</div></div><br>
<div></div><div><div><b>
Grasping/Feeling:</b> Must be able to type, handle documents, and use equipment and electronic devices.<br>
</div><div></div><div> X</div></div><br>
</div>
<p></p>
<ul><li>The work environment is usually a well-lighted, environmentally controlled indoor environment with moderate level of noise.</li><li>
Works in an office environment with the option for some remote work.</li></ul>
<p>
The statements herein are intended to describe the general nature and level of work being performed but are not to be seen as a complete list of responsibilities, duties, and skills required of personnel so classified. Also, they do not establish a contract for employment and are subject to change at the discretion of the employer.</p>
<p>
Created: 12.13.2023; Updated: 11.07.2024; 12.31.2025</p></div>

Nurse Care Manager RN (PT H)

CenterWell

<div><h1 class="jobSectionHeader"><b>Become a part of our caring community</b><br>
</h1>
The Clinical Care Nurse (RN) is a clinic-based nursing role focused on improving patient outcomes. You will support safe Transitions of Care (TOC), reduce avoidable ED utilization, and drive Medicare Advantage Stars and quality performance. The Clinical Care RN plays a critical role in advancing clinical quality and supporting patients across transitions of care to improve patient outcomes.
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CenterWell/Conviva clinic locations may be available in the following areas: Stone Mountain, Suwanee<br>
<br>
As a Clinical Care RN, you will contribute to Medicare Advantage Stars ratings by proactively identifying care opportunities, engaging patients and providers, and driving evidence-based interventions. You will balance direct patient education and outreach with data-driven quality improvement efforts. The Clinical Care RN aligns daily responsibilities with organizational values, integrity, respect, empathy, and commitment to health equity &ndash; to enhance patient health outcomes and satisfaction.<p></p><div><div><p><b>
Role Scope</b></p></div><div><ul><li><p>
Transitions: Care transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observation and emergency department patients.</p></li></ul></div><div><ul><li><p>
Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based population.</p></li></ul></div><div><ul><li><p>
Population Health: Deliver culturally appropriate chronic disease education to activate patients are chronic disease self-management, particularly in DM, HTN, CHF and COPD.</p></li></ul></div><p></p><div><p><b>
Duties and Responsibilities</b>:</p></div><div><ul><li><p>
Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to Stars and HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities.</p></li></ul></div><div><ul><li><p>
Proactively identify recently discharged inpatient, observation and emergency department patients and coordinate timely post-discharge follow-up in alignment with TOC and Transitional Care Management (TCM) requirements, with the aim of addressing root causes of utilization and supporting patients to prevent avoidable readmissions or return visits.</p></li></ul></div><div><ul><li><p>
Conduct targeted patient and provider outreach via phone, telehealth and in-clinic visits to close care opportunities, provide tailored education on preventive care, chronic disease management, and medication management.</p></li></ul></div><div><ul><li><p>
Conduct post-discharge outreach to assess understanding of discharge instructions, bottles-out medication reconciliation, symptom monitoring, and follow-up appointment adherence. Identify and escalate barriers, collaborating with providers and care team to prevent readmissions and avoidable ED utilization.</p></li></ul></div><div><ul><li><p>
Collaborate effectively with interdisciplinary teams, including providers, care assistants, center administrators, medical assistants, pharmacy, and quality improvement staff&mdash;to implement evidence-based interventions and optimize workflows.</p></li></ul></div><div><ul><li><p>
Document all outreach efforts, clinical interactions, and outcomes accurately and in compliance with organizational and CMS regulatory standards.</p></li></ul></div><div><ul><li><p>
Prepare, participate and discuss patients in center huddles and high-risk rounds with providers and the center-based and interdisciplinary team.</p></li></ul></div><div><ul><li><p>
Participate in quality improvement projects, provider education sessions, team huddles to stay current with evolving clinical guidelines and organizational priorities.</p></li></ul></div><div><ul><li><p>
Monitor progress toward Stars and Transitional Care Management goals, proactively identify barriers, and help develop innovative solutions to improve clinical performance and patient engagement.</p></li></ul></div><div><ul><li><p>
Support clinic operations through provider collaboration, care coordination, and community education initiatives.</p></li></ul></div><div><ul><li><p>
Coordination and facilitation of center and market-based Wellness Events-focused in-person engagement for Stars care opportunity closures.</p></li></ul></div><div><ul><li><p>
Maintain patient confidentiality in accordance with HIPAA.</p></li></ul></div></div><div><ul><li><p>
Document patient encounters accurately and timely in the indicated platform (e.g., medical record).</p></li></ul></div><div><ul><li><p>
Follow organizational policies related to safety, infection control, and attendance.</p></li></ul></div><div><ul><li><p>
Perform other duties as assigned.</p></li></ul></div><p></p><h1 class="jobSectionHeader"><b><br>
Use your skills to make an impact</b><br>
<b>
</b></h1><div><div><p><b>Required Qualifications:</b></p></div><div><ul><li><p>
Must meet one of the following requirements: Associate&rsquo;s degree in nursing (ADN) or Bachelor&rsquo;s degree in nursing (BSN).</p></li></ul></div><div><ul><li><p>
Active, unrestricted RN license (state specific as applicable).</p></li></ul></div><div><ul><li><p>
3+ years' clinical nursing experience with exposure to transitions of care, quality improvement, managed care, or population health management.</p></li></ul></div><div><ul><li><p>
Proficiency with electronic health records (e.g., Athena EMR), data analytics tools (e.g., DataHub, Compass Rose, SalesForce HealthCloud &ndash; per your prior employer&rsquo;s population health tools), and Microsoft Office Suite.</p></li></ul></div><div><ul><li><p>
Willing and able to complete and maintain Basic Life Support training.</p></li></ul></div><p></p><div><p><b>
Preferred Qualifications:</b></p></div><div><ul><li><p>
Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements.</p></li></ul></div><div><ul><li><p>
Experience with Transitions of Care, hospital discharge or ER follow up programs.</p></li></ul></div><div><ul><li><p>
Strong clinical judgment, data analysis skills, and ability to apply evidence-based practices.</p></li></ul></div><div><ul><li><p>
Excellent communication and motivational interviewing skills to educate and empower members.</p></li><li><p>
Proficiency in both English and Spanish is strongly preferred.</p></li></ul></div><div><ul><li><p>
Commitment to health equity, inclusiveness, and patient-centered care.</p></li></ul></div><div><ul><li><div><p>
Basic Life Support trained.</p></div></li></ul><p></p><p><b>
Additional Information</b></p></div><div><p><b><i>
Core Competencies:</i></b></p></div><div><ul><li><p>
Clinical quality improvement and strategic gap closure.</p></li></ul></div></div><div><div><ul><li><p>
Transitions of Care coordination and post-discharge support.</p></li></ul></div><div><ul><li><p>
Member and provider engagement with motivational interviewing.</p></li></ul></div><div><ul><li><p>
Regulatory compliance and documentation accuracy.</p></li></ul></div><div><ul><li><p>
Data interpretation and actionable reporting.</p></li></ul></div><div><ul><li><p>
Cross-functional collaboration and teamwork.</p></li></ul></div><div><ul><li><p>
Time management balancing administrative and outreach duties.</p></li></ul></div><p></p><div><p><b><i>
Values &amp; Mission Alignment:</i></b></p></div><div><ul><li><p>
Demonstrate integrity, respect, and empathy in all interactions.</p></li></ul></div><div><ul><li><p>
Uphold the mission to improve health outcomes and member satisfaction through proactive, compassionate care.</p></li></ul></div><div><ul><li><p>
Champion continuous learning, innovation, and professional growth.</p></li></ul></div><p></p><div><p><b><i>
Work Information:</i></b></p></div><div><p>
This role requires an in-center presence, involving daily commute to assigned clinic(s) and occasional (quarterly) travel within the market to alternative clinic(s) for strategic meetings.</p></div><div><ul><li><p><b>
Workstyle: Clinic-based, in-center 5 days per week</b><b>.</b></p></li></ul></div><div><ul><li><p><b>
Location:</b> Must reside in designated market area, in reasonable commutable distance to assigned clinic(s).</p></li></ul></div><div><ul><li><p><b>
Hours: </b>Monday&ndash;Friday, 8:00 AM&ndash;5:00 PM; additional time may be required.</p></li></ul></div><p></p><div><p><b><br>
TB Statement</b>:</p></div><div><p>
This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.</p></div><p></p><div><p><b><br>
Driving Statement</b>:</p></div></div><div><p>
This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.</p></div><p></p><p><b>
Scheduled Weekly Hours</b></p><p></p>
40<p></p><p><b>
Pay Range</b></p>
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.<br>
<p></p>
$71,100 - $97,800 per year<br>
<p></p>
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.<p></p><p><b>
Description of Benefits</b></p>
Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.<p></p><h1 class="jobSectionHeader"><b><br>
About Us</b><br>
</h1>
About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient&rsquo;s well-being.<p></p>
About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com.<p><br>
<br>
<b>Equal Opportunity Employer</b></p><p></p><p>
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.</p></div>

Clinical Care Nurse (RN)

EngageMED

<div><p><b>Job Title: LPN Quality &amp; AWV (Annual Wellness Visit) Coordinator</b></p><p><b>
Department</b>: Quality</p><p><b>
Reports To</b>: RN Clinical Quality Manager</p><p><b>
FLSA Status</b>: Full-Time (Non-Exempt)</p><p><b>
Overview</b>: At EngageMED, we embrace and practice patient-centered care and we strive to provide all of our patients with the best possible medical care. We encourage each patient to take an active role in their healthcare. We believe that in addition to helping patients when they are sick, we can and should help guide them in making healthy choices for preventive care. The Quality &amp; Annual Wellness Visit Coordinator will perform Annual Wellness Visits per payer guidelines, promote preventative patient care, offer screening services, and coordinate disease management services with the provider, patient and their family. This Nurse will review health maintenance and educate on the same, and will collaborate with providers to order due or overdue preventive health tests and immunizations.</p><p><b>
Position Summary</b></p><p>
The LPN Quality &amp; AWV Coordinator is responsible for the coordination, scheduling, and completion of Annual Wellness Visits (AWVs) for eligible patients across assigned primary care clinics. This role supports quality improvement initiatives and value-based care performance, including MSSP and Medicare Advantage programs, by improving AWV completion rates and closing preventive care gaps.</p><p>
The LPN AWV Coordinator will conduct AWVs in-person and via telehealth (audio and audio/visual), ensuring accurate documentation, patient engagement, and adherence to CMS/payer guidelines and organizational workflows.</p><p><b>
Key Responsibilities</b></p><ul><li>
Identify eligible patients for Annual Wellness Visits (AWVs) using reporting tools, EHR registries, and payer lists</li><li>
Proactively outreach and schedule AWVs for patients across assigned clinics</li><li>
Conduct AWVs in-person, via telephone (audio-only), or audio/visual platforms in accordance with CMS/payer guidelines</li><li>
Complete all required AWV documentation in the electronic health record (EHR), ensuring accuracy and compliance</li><li>
Utilize standardized workflows, templates, and evidence-based tools during AWV completion</li><li>
Identify and address care gaps, including preventive screenings, immunizations, and chronic disease management needs</li><li>
 Coordinate with providers, care coordinators, and clinic staff to ensure appropriate follow-up and continuity of care</li><li>
 Educate patients on preventive health measures, self-management, and available services</li><li>
 Support Medicare Shared Savings Program (MSSP) and Medicare Advantage quality performance initiatives</li><li>
 Track and monitor AWV completion rates and assist in achieving organizational quality benchmarks</li><li>
 Communicate effectively with patients, providers, and interdisciplinary team members</li><li>
 Travel between assigned clinic locations as needed (if applicable)</li><li>
Perform other duties as assigned to support clinic operations and quality initiatives</li></ul><p><b>
Minimum Qualifications</b></p><p><b>
Education:</b></p><ul><li>
Graduate of an accredited Licensed Practical Nursing (LPN) program</li></ul><p>
Licensure:</p><ul><li>
Current, unencumbered LPN license in the State of Arkansas</li></ul><p><b>
Experience:</b></p><ul><li>
Minimum of 1&ndash;2 years of clinical experience in a primary care or ambulatory setting preferred</li><li>
 Experience with Medicare Annual Wellness Visits, population health, or care coordination preferred</li><li>
Familiarity with EHR systems and clinical documentation workflows preferred</li></ul><p><b>
Knowledge, Skills, and Abilities:</b></p><ul><li>
Strong understanding of preventive care and chronic disease management</li><li>
 Knowledge of Medicare Annual Wellness Visit requirements and documentation standards</li><li>
 Ability to effectively engage patients via phone and telehealth platforms</li><li>
 Strong organizational and time management skills with ability to manage scheduling workflows</li><li>
Attention to detail and accuracy in documentation</li><li>
 Ability to work independently while supporting a remote, team-based environment</li><li>
 Effective communication and interpersonal skills</li><li>
 Basic computer proficiency, including EHR systems and reporting tools</li></ul><p><b>
Work Environment &amp; Expectations:</b></p><ul><li>
 Position supports multiple clinics with a focus on improving AWV and quality performance</li><li>
Work may be performed in clinic settings, remotely, or in a hybrid model depending on organizational needs</li><li>
 Requires frequent patient interaction via phone and/or telehealth platforms</li></ul></div>

LPN Quality & AWV Coordinator- Glenwood Family Clinic

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