Duties: Serves as Nurse for Population Health Improvement. Manages the health metrics and outcomes of the primary care population. Responsible for the coordination of Population Health for enrolled beneficiaries. Serves as the Clinical Practice Guideline Coordinator (CPG coordinator), managing the Military Health System Population Health Portal (MHSPHP), and related automated population health web-based applications outcomes data to determine program needs. Coordinates the implementation of clinical practice guidelines to support Army Medical Department (AMEDD) prevention and disease management-based population health initiatives through consultation and collaboration with health care providers, clinical and administrative support staff, and patients. 1. a. Assists to standardize Disease Management across the patient care continuum by monitoring Disease Management of the patient in accordance with the clinical practice guidelines. Identifies resources to integrate Clinical Practice Guidelines into all clinical areas, promoting and facilitating implementation, evaluation and sustainment of evidence-based practice across the care continuum. As an imbedded staff member within the PCMH practice, serves as crucial link between health care providers, members of the primary care team, and Nurse Case Managers in order to identify beneficiaries with short- and long-term health care needs. Identifies and facilitates reporting of process improvements to the CPG Guideline Champions and executive level committees. Serves as a population health resource. Attends conferences, committee meetings related to Clinical Practice Guidelines and medical management activities. Standardizes Disease Management across the patient care continuum by monitoring Disease Management of the patient in accordance with the Clinical Practice Guidelines and identifying resources to integrate Clinical practice Guidelines and supporting continuity of care. Conducts specific quality improvement (QI) studies to assist in process improvement related to population health. Develops the process for evaluation of clinical practice guideline outcome data for opportunities to continually improve patient care processes. Works closely with the Nurse Case Managers and the primary care team to ensure patient-centered, whole-person concept within each encounter. Proactively engages with care teams and patients to ensure population health activities are integrated into and standardized as part of each patient encounter. Provides data support to stakeholders in support of population health and medical management activities. b. Utilizes the six core principles of population health management (i.e. identification and assessment, demand forecasting, demand management, capacity management, evidenced-based care and prevention, and program evaluation and feedback), as a framework for providing population-based health interventions to the enrolled population. Applies epidemiological methods to describe the population and its risks, identifying and employing evidence-based interventions and managing information. Identifies strategies designed to improve patient access, improve adherence to population health metrics, and reduce administrative burdens for DoD beneficiaries and improve the cost effectiveness for the civilian/military system of health care delivery. Obtains feedback from Resource Management, TRICARE, and the Health Care Finders to identify problem areas. Proposes regulatory and administrative changes to resolve identified problems. 2. Characterizes populations and sub-populations by disease categories, forecasts demand, forecasts demand management, capacity management, evidence-based care and prevention. Conducts population health and medical management program evaluation and feedback, interprets data and makes evidence-based recommendations. Promotes and optimizes medical readiness of active-duty members, improves the efficiency and effectiveness of the medical treatment facility healthcare delivery system, and improves population health status of the eligible beneficiary population. Performs other duties as assigned.