Population Health Nurse Coordinator

The Population Health Nurse Coordinator is responsible for coordinating and managing technology-enabled and longitudinal care management services, including telehealth, Remote Patient Monitoring (RPM), and Chronic Care Management (CCM), for primary care patients. The position collaborates with providers, clinical staff, patients, caregivers, and community resources to improve health outcomes, enhance patient engagement, reduce avoidable healthcare utilization, and support continuity of care. The Coordinator oversees patient monitoring, care plan implementation, care coordination activities, and regulatory compliance while supporting quality improvement and population health initiatives.

Essential Duties & Responsibilities:

• Coordinates telehealth, Remote Patient Monitoring (RPM), and Chronic Care Management (CCM) services for eligible primary care patients
• Identifies and assists with enrollment of appropriate patients into telehealth, RPM, and CCM programs
• Educates patients and caregivers regarding program participation, monitoring equipment, care plans, and follow-up expectations
• Reviews and monitors patient-reported information and remote physiologic monitoring data according to established protocols
• Assesses patient symptoms, clinical concerns, and changes in condition and communicates significant findings to the appropriate provider
• Implements, monitors, and updates patient care plans in collaboration with physicians, advanced practice providers, and other members of the healthcare team
• Serves as a primary coordinator of disciplines and services to support well-coordinated, patient-centered care
• Provides ongoing outreach and follow-up for patients with chronic medical conditions
• Assists patients with medication management, health education, disease self-management, preventative care, and adherence to treatment plans within the scope of nursing practice
• Coordinates referrals, follow-up appointments, diagnostic testing, and other healthcare services as appropriate
• Documents patient interactions, clinical assessments, monitoring activities, care coordination, and time spent providing applicable services in the electronic medical record
• Ensures required documentation is completed to support telehealth, RPM, and CCM program requirements
• Collaborates with clinic leadership and providers to develop and maintain workflows, policies, protocols, and processes related to telehealth, RPM, and CCM services
• Assists with monitoring program performance, patient participation, clinical outcomes, and opportunities for improvement
• Assists with audits, quality reviews and reporting activities related to care management programs.
• Supports other primary care clinic nursing functions as needed
• Demonstrates clear ownership of workplace and patient safety.
• Reports mistakes, near misses, adverse events, and quality and safety concerns.
• Protects patient confidentiality and abides by all HIPAA and privacy laws.
• Other duties as may be assigned.

Job Requirements:

Education: Graduate of an accredited school of Nursing. BSN preferred.

Licensure/Certification: Current Registered Nurse license in the State of Indiana. Current BLS certification required.

Experience: Previous nursing experience required. Experience in primary care, ambulatory care, care coordination, chronic disease management, population health, telehealth, or remote patient monitoring preferred.

Knowledge/Skills: Strong clinical assessment, communication, organization, and patient education skills. Ability to independently prioritize patient needs, coordinate care across multiple providers and services, and effectively utilize electronic medical records and telehealth technology.