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Population Health Nurse (RN/LPN)

FTE – Full-time

Location:  Gwinn, MI

The Population Health Nurse will assist with clinical quality improvement and population health of all service areas including medical, behavioral health and dental.


 Assists with Clinical Quality Improvement and Population Health Initiatives 

  1. Pulls reports as directed from Electronic Health Record (EHR) or other clinical patient information registry to identify patient gaps in care
  2. Navigates through the EHR to verify the patient gaps in care or identify documentation to satisfy patient gaps in care
  3. Documents in the EHR or other clinical patient information registry appropriately to satisfy patient gaps in care
  4. Utilizes professional communication and telephone skills to contact patients with gaps in care to schedule appointment with appropriate primary care provider or specialty care provider and/or utilize standing orders
  5. Utilizes motivational interviewing and provides patient education as needed
  6. Completes required documentation to track progress through PDSA (plan-do-study-act) cycles as related to quality work plan measures
  7. Prepares monthly reports on quality work plan measures as directed
  8. Coordinates large scale outreach efforts through the EHR regarding a relevant clinical quality measure
  9. Assists clinic nursing staff with following up on outstanding tests and referrals


  1. Maintains established organizational policies and procedures, objectives, performance improvement program, safety, environment of care, management of information, and infection control standards.
  2. Complies with federal and state law, regulations, accrediting and licensing agencies at all times.
  3. Provides patient support and assures the provision of emotions and physical care of patients of all ages, including: promoting positive relationships between patients, staff, families and visitors; assessment of the effects of cultural, social, economic, and religious influence of patients.
  4. Works cooperatively with providers and personnel to carry out the goals and objectives of the UGLFHC.
  5. Establishes and maintains effective working relationship with appropriate personnel and agencies.
  6. Performs safe emergency techniques according to clinic/department policies/procedures.
  7. Performs other related duties as assigned or requested.

Education, Training, Licensing and Credentialing

Minimum Education:

  • Registered Nurse (RN) OR Licensed Practical Nurse (LPN) with active state of Michigan license 

Experience and Skills


  1. Computer skills including Microsoft suite including Excel and prior electronic health record experience.
  2. Well-developed verbal and written communication skills in English.
  3. Experience and ability to maintain confidentiality under HIPAA standards.
  4. The ability to exercise a high degree of diplomacy and tact; excellent customer services and interpersonal communication skills; Cultural sensitivity and demonstrated ability to work with diverse individuals and groups.
  5. Organizational and administrative skills with meticulous attention to detail
  6. Ability to work independently with minimal supervision.
  7. Possesses flexibility and willingness to handle a variety of tasks.


  1. Knowledge of medical terminology
  2. Knowledge and work experience in quality/process improvement.
  3. Computer skills including data reporting tools and data management systems.
  4. Knowledge of Federally Qualified Health Center (FQHC) standards of practice, legal and ethical codes and regulations applicable to FQHCs.
  5. Knowledge of PCMH model of care.
  6. Clinical experience in an outpatient setting, preferably in an FQHC.

Physical Demands, Working Conditions and Travel Requirements

Physical Demands:

  1. Sedentary work in an office setting
  2. Ability to communicate verbally and respond effectively
  3. Occasional reaching, stooping, bending, kneeling and crouching
  4. Requires visual acuity to perform required tasks

Working Conditions:

  1. May be exposed to the risk of blood borne diseases
  2. May be exposed to infections and contagious diseases
  3. May be exposed to housekeeping/cleaning agents/chemicals
  4. Contact with patients under wide variety of circumstances
  5. Subject to varying and unpredictable situations
  6. Occasional pressure due to multiple tasks, calls and inquiries

Travel Requirements

  1. Ability to accept travel assignments as required to perform duties.

Upper Great Lakes Family Health Center (UGL) is a Federally Qualified Health Center and is a Federal Tort Claims Act (FTCA) Deemed Facility.
UGL receives funding from The U.S. Department of Health and Human Services and has Federal Public Health Service deemed status with respect to certain health or health-related claims, including medical malpractice claims for itself and its covered individuals.
This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H80CS26511 Health Center Cluster, total award amount of $1,839,050 with 89.9 % financed from nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.