Population Health Care Manager

Position: Population Health Care Manger

Reports to: Care Manager Supervisor

FLSA Status: Hourly/Full-time

Position Summary:

We are seeking a full-time Registered Nurse (RN) to support our Medicare population through proactive outreach, pre-visit planning, and care gap closure.

This role focuses on reviewing patient charts, contacting patients prior to appointments, and ensuring all preventive care, screenings, and documentation are complete before the visit. The goal is to improve patient outcomes, support efficient provider visits, and enhance performance in value-based care programs.

This is a proactive, population health role focused on prevention, patient engagement, and quality improvement, rather than traditional bedside care. Population health nurses play a key role in improving outcomes through prevention, outreach, and coordination of care.

Duties/Responsibilities:

• Review Medicare patient charts prior to scheduled visits
• Identify and address care gaps before the appointment
• Ensure charts are accurate, complete, and up to date
• Contact Medicare patients by phone prior to their visit
• Complete screenings and questionnaires (e.g., PHQ-9, preventive screenings)
• Review and update preventive care needs, chronic conditions, and care gaps
• Educate patients on needed screenings and services
• Coordinate completion of labs, imaging, and referrals
• Ensure completion and documentation of Annual Wellness Visit (AWV) requirements, advanced directives, immunizations, and preventive screenings
• Support Medicare wellness visit workflows
• Assist providers in ensuring diagnoses are documented to the highest level of specificity
• Support accurate and complete documentation for risk adjustment and quality reporting
• Review charts for missing or incomplete diagnoses
• Track and close care gaps tied to Medicare and value-based care metrics (VBR, HEDIS, MIPS)
• Monitor performance and identify opportunities for improvement
• Support quality improvement initiatives including PDSA cycles and workflow improvements
• Collaborate with providers and care team to ensure follow-through
• Assist with referrals, follow-ups, and transitions of care
• Support high-risk Medicare patients as needed
• Document all outreach and updates in the EHR
• Track completion of screenings and interventions
• Assist with reporting and quality tracking
• Maintain required documentation for all care management activities
• Ensure compliance with HIPAA and related information security policies
• Other duties as assigned

Education and Experience:

Required :

• Active Registered Nurse (RN) license
• Strong communication skills, especially phone-based outreach
• Experience using EHR systems
• Highly organized and detail-oriented
• Self motivated

Preferred:

• Minimum of 2 years nursing experience
• Experience in primary care or outpatient setting
• Experience with:
• Medicare population management
• Annual Wellness Visits (AWV)
• Care gap closure workflows
• Population health or care coordination
• Quality programs (HEDIS, VBR, MIPS)

Physical Requirements:·

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift up to 15 pounds at times.

Benefit Conditions:

• Waiting period may apply

This Company Describes Its Culture as:

• Outcome-oriented -- results-focused with strong performance culture
• People-oriented -- supportive and fairness-focused
• Team-oriented -- cooperative and collaborative

This Job Is Ideal for Someone Who Is:

• Communicates with warmth, clarity, and professionalism, putting patients at ease during every interaction (Patient Centered, Customer Service)
• Takes pride in accuracy and follows through on details without being reminded (Honesty, Financially Responsible)
• Manages their own workload and patient panel with confidence and minimal oversight (Self-Care, Loyalty)
• Stays ahead of the work rather than reacting to it, identifying gaps and acting before they become problems (Evidence Based, Teamwork)
• Juggles competing priorities without dropping the ball (Financially Responsible, Self-Care)
• Shows up consistently, follows through reliably, and can be counted on by their team and their patients (Loyalty, Honesty)
• Genuinely enjoys people and finds meaning in collaboration, whether with patients, providers, or colleagues (Teamwork, Patient Centered, No Gossip/Negativity)

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person