Registered Nurse (RN)- Population Health, Remote, Full-Time, Days

Responsible for non-face-to-face post-discharge outreach calls to patients, reviewing discharge summaries and instructions, performing medication reconciliation, assessing patient understanding of discharge plans, coordinating follow-up with providers and care teams, documenting interactions in the EHR, scheduling appointments, and supporting readmission prevention. Provides hypertension-focused education and facilitates appropriate follow-up, collaborates with providers and care coordination teams to close care gaps (e.g., hypertension control, diabetes monitoring, preventive screenings), ensures compliance with CMS requirements, and delivers appropriate telephonic nursing guidance and discharge teaching. Remote position for TN residents with emphasis on population health outreach and coordination within an ambulatory quality and reliability workflow; maintains documentation for billing and compliance and participates in quality improvement initiatives.