Population Health Nurse

CenterWell • Houston, TX

4d

About The Position

The Population Health RN (PHN) is a market-level clinical leadership role responsible for improving outcomes, care coordination, and utilization management for high-risk senior populations. Reporting directly to the Market Chief Medical Officer, the PHN serves as a strategic and operational partner to physicians, clinic teams, and market leaders to advance value-based care performance. Initial population focus will include: · Patients admitted to, or at high risk for admission to, out-of-network (OON) hospitals · Patients with advanced kidney disease, specifically ESRD and CKD Stages 4 and 5 The PHN integrates transitions of care, clinical navigation, and population health strategies to reduce avoidable utilization, improve affordability, enhance patient experience, and support high-quality, patient-centered care. This role blends direct patient intervention with data-driven analysis and program development and will help define workflows and best practices as population health capabilities mature within the market.

Requirements

• Active, unrestricted Registered Nurse (RN) license in the state of practice.
• Associate’s or Bachelor’s degree in Nursing (ADN or BSN).
• 3+ years of clinical nursing experience, with exposure to one or more of the following: Transitions of care Population health or care management Chronic disease management Hospital, post-acute, or managed care environments
• Strong clinical judgment, critical thinking, and care coordination skills.
• Proficiency with EMR systems and basic data analysis tools.
• Ability to work independently while collaborating effectively across teams.

Nice To Haves

• 5+ years of experience in population health, care management, nephrology, dialysis, or complex care navigation.
• Experience with ESRD and advanced CKD populations.
• Experience with utilization management and hospital transitions, including post-discharge follow-up.
• Knowledge of Medicare Advantage, Stars, HEDIS, and value-based care models.
• Certification in Case Management (CCM) and/or Nephrology Nursing (CNN).
• Experience in program development or workflow design.
• Bilingual proficiency (market dependent).

Responsibilities

• Lead proactive identification and outreach for high-risk patients, with emphasis on: · Out-of-network hospital admissions · Patients at risk for inpatient, observation, or ED utilization · ESRD and advanced CKD (Stages 4–5) populations
• Provide end-to-end transitions of care support, including inpatient, ED, observation, and post-acute transitions.
• Conduct goals of care conversations and provide support for palliative and hospice care discussions
• Conduct post-discharge follow-up aligned with Transitional Care Management (TCM) requirements to reduce avoidable readmissions and ED returns.
• Identify and track OON admissions using EMR and utilization data.
• Partner with providers, care teams, and leadership to intervene early and address drivers of OON utilization.
• Support care continuity post-discharge, including medication reconciliation, follow-up scheduling, and specialist coordination.
• Escalate systemic barriers impacting network alignment, access, or care coordination to the MCMO and market leadership.
• Provide education to patients on in-network hospitals and call us first services
• Serve as a clinical navigator for patients with ESRD and CKD Stages 4–5.
• Collaborate with dialysis centers to ensure completion and submission of CMS Form 2728 for ESRD patients
• Conduct comprehensive assessments to understand clinical, social, and system-level needs.
• Collaborate with PCPs, nephrologists, and interdisciplinary teams to support individualized care plans.
• Educate patients and caregivers on disease progression, treatment options, self-management, and care planning.
• Analyze clinical and utilization data to identify trends and care gaps related to: · Medicare Advantage Stars · HEDIS · Utilization and avoidable admissions
• Prioritize interventions that improve quality performance, affordability, and patient outcomes.
• Support accurate documentation, coding, and care gap closure in partnership with providers and clinic teams.
• Work closely with physicians, clinic staff, pharmacy, care assistants, and quality teams to implement evidence-based interventions.
• Participate in huddles, high-risk rounds, and case conferences.
• Contribute to the development and refinement of population health workflows, particularly for kidney care and hospitalization management.
• Provide informal education and clinical support to care teams related to population health priorities
• Coordinate with Integrated Home Care Program and CW Home Health to reduce unnecessary hospital utilization
• Document patient outreach, assessments, interventions, and outcomes accurately and timely in the medical record.
• Ensure compliance with HIPAA, CMS requirements, and organizational policies.
• Maintain confidentiality, safety standards, and professional conduct.

Benefits

• Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree