Population Health Nurse | Custer Clinic | Full Time – 40 Hours

Custer, SD USA Full time 25_262


Current Employees:

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Starting Pay Rate Range

$32.40 - $40.50

(Determined by the knowledge, skills, and experience of the applicant.)

Job Summary

At Monument Health, we’re committed to providing high-quality, patient-centered healthcare. We’re looking for a population health nurse to join our team and help us achieve our goal of improving the health of the communities we serve. The Population Health Nurse will work in collaboration with primary care providers and healthcare teams. Primary responsibilities will include identification of managed care 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 include but is not limited to responsibility for other programs to include Transitional Care Management, coordinating efforts with Post-Acute Care providers (Skilled Nursing Facilities and Home Health), or integration of Behavioral Health services. He or she will be responsible for developing and implementing population health initiatives, working with community partners to promote healthy lifestyles, and conducting outreach to at-risk populations. The population health nurse will also be responsible for data collection and analysis to assess the impact of our programs.

Monument Health offers competitive wages and benefits on qualifying positions. Some of those benefits can include:

*Supportive work culture

*Medical, Vision and Dental Coverage

*Retirement Plans, Health Savings Account, and Flexible Spending Account

*Instant pay is available for qualifying positions

*Paid Time Off Accrual Bank

*Opportunities for growth and advancement

*Tuition assistance/reimbursement

*Excellent pay differentials on qualifying positions (extra pay for working evening, nights or weekends)

*Flexible scheduling

Job Description

Essential Functions:

  • Serve as a liaison between patients, families, and the interdisciplinary healthcare team to ensure that patient needs are met.
  • Conduct health risk assessments and screenings, providing education and referrals as needed.
  • Develop and implement population health initiatives aimed at improving the health of defined patient populations.
  • Monitor and evaluate the effectiveness of population health interventions.
  • Collect and analyze data to identify trends and areas for improvement in population health.
  • Serve as a resource to other nurses and healthcare professionals on population health topics.
  • Advocate for policies and practices that improve population health.
  • Collaborate with community partners to develop and implement programs that address social determinants of health.
  • Disseminate information on best practices in population health.
  • Provide leadership and direction in the development of population health programs.
  • Works collaboratively with members of the care team to develop a process to track Annual Wellness Visit (AWV) scheduling and ensure that patient records are reviewed to identify care gaps prior to visit with the clinician.
  • Post reminders to secure that all co-morbidities are discussed and documented during AWV.
  • Establish competencies related to AWV screenings such as PHQ-9, TUG and Mini-Cog and assists in the training of the care team to perform these screenings.
  • Establish counseling services/resources within the practice to assist with obesity, tobacco cessation, diabetes prevention/management, hypertension management, depression, anxiety and advanced care planning.
  • Stratify patient population according to risk to effectively and efficiently manage patients with multiple chronic diseases; determine frequency for clinician visit and CCM encounters; maximize use of qualified clinical staff within the care management team to provide appropriate non-face-to-face patient contact.
  • In collaboration with the primary care physicians, develop a care plan based on mutual goals with the patient and family; monitor patient adherence to care plan and progress toward goals and facilitate changes as needed.
  • Participate in huddles with primary care physician and care team; identify scheduling opportunities, special needs for patients, patients who need care outside of their scheduled visit, patients overdue for AWV and those with missed appointments requiring rescheduling.
  • Collaborate with practice leaders to implement effective internal tracking systems for patients such as patient panels, AWV scheduling, transition of care follow-up calls/visits, and CCM encounters.
  • Collaborate with stakeholders to establish a method for assigning patients into a panel listing by clinician that is routinely utilized for scheduling purposes; utilize empanelment method to ensure that preventive, chronic, and acute needs of all patients are met, including both high and low utilizers.
  • Other duties as assigned.

Additional Requirements

Education - Completion of a nursing education program that is approved by a board of nursing

Certification - Registered Nurse (RN) - South Dakota Board of Nursing; Certified Care Manager certification (in place or acquired within 12 months); Health Coaching Certification (in place or acquired within 12 months)

Experience - 2+ years caring for chronic disease patients


Experience - 2+ years provider practice or clinic health; 2+ years Care Coordination, Case Management, Home Health or Behavior Health; 2+ years health information systems

Physical Requirements:
Medium work - Exerting up to 50 pounds of force occasionally, and/or up to 30 pounds of force frequently, and/or up to 10 pounds of force constantly to move objects.

Job Category


Job Family

Ambulatory Nursing


CS Value Based Incentive Program

Scheduled Weekly Hours



Employee Type


15 Corporate Services Division

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Monument Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.