RN/LVN Nurse Coordinator for Population Health & Complex Care

Frontier Direct, LLC • Harlingen, TX

4d

About The Position

The RN/LVN Nurse Coordinator for Population Health & Complex Care drives measurable population health outcomes and medical and pharmacy cost optimization across Frontier’s highest-risk members. The role operationalizes population health protocols, provides concierge-level care coordination for complex case members, and prepares AI-assisted medical case review packets for Medical Director sign-off. The coordinator partners closely with Frontier clinic staff in patient care, supports employer events, and leads high-touch outreach. The work emphasizes standards, checklists, and timeliness. The position has functional, dotted-line oversight of queue work but no HR supervision duties.

The coordinator maintains population health registries and queues for hypertension, diabetes, asthma, chronic kidney disease, and lipids; proactively contacts members outside target metrics and coordinates follow-up care with Frontier PCPs. For complex and high-risk members, the coordinator manages longitudinal care plans, conducts prompt follow-up after emergency, hospital, and specialist care, prepares clinical pre-briefs, and tracks action-item completion. The role also supports medication-cost optimization through alternative sourcing, preferred pharmacy routing, patient assistance programs, and manufacturer copay assistance.

The position requires accurate and timely EHR documentation and adherence to HIPAA, infection-control, and clinic-safety protocols, as well as maintaining current licensure, certifications, and clinical competencies. The role is eligible for an annual performance bonus; the amount, metrics, and payout structure will be determined by the manager and shared after the employee’s start date.

Requirements

• Active, unrestricted Texas LVN or RN license in good standing with the Texas Board of Nursing.
• Proven track record in high-touch patient care, motivational interviewing, and phone/SMS engagement with complex patients.
• Ability to manage clinical registries and execute protocolized care pathways.
• Comfort using AI-assisted workflows to synthesize medical records and prepare clinical review packets that compile clinical context for provider decision-making.
• Accuracy and follow-through.
• Pleasant and courteous member interaction.
• Teamwork.

Nice To Haves

• Three or more years of case management, chronic disease management, or ambulatory/value-based care experience.
• Bilingual English/Spanish.

Responsibilities

• Maintain protocolized hypertension, diabetes, asthma, chronic kidney disease, and lipid registries and queues.
• Proactively contact members who are outside clinical targets and schedule follow-up visits.
• Coordinate repeat biometric checks, home blood pressure and glucose log reviews, standing lab orders, and medication-titration follow-ups with Frontier PCPs until clinical markers reach target.
• Manage an active cohort of complex or high-risk claimants through high-touch care coordination and longitudinal care plans.
• Conduct post-discharge and post-visit follow-up calls within 24–48 hours of emergency room visits, hospitalizations, or specialist consultations to reconcile care plans, prevent readmissions, and close care gaps.
• Prepare concise, templated clinical pre-briefs containing the problem list, latest biomarkers, medication list, care gaps, owner, and due date.
• Participate in weekly Complex Case Conferences with the DPC+ Medical Director.
• Track weekly complex-care action items to achieve at least 90% closure within seven calendar days and transition stabilized patients back to standard primary care management.
• Coordinate with patients on alternative medication sourcing, preferred pharmacy routing, Patient Assistance Programs, and manufacturer copay assistance to lower employer and member drug spend.
• Conduct 7-to-14-day post-medication follow-up.
• Support employer events and lead high-touch outreach.
• Provide functional, dotted-line oversight of queue work; the role has no HR supervision duties.
• Maintain accurate, timely EHR documentation of patient encounters, outreach interactions, and treatments.
• Follow HIPAA, infection-control, and clinic-safety protocols and maintain current licensure, certifications, and required clinical competencies.

Benefits

• Medical, dental, and vision insurance.
• Frontier Membership for the employee and immediate family.
• Voluntary short-term disability, long-term disability, life insurance, and other supplemental insurance.
• 401(k) plan.
• Free access to financial wellness platforms with financial advisors and personal finance tools.
• Paid time off, including up to five unplanned days off per year.
• Nine company holidays per year.
• Parental leave policies.
• Eligibility for an annual performance bonus, subject to quality, safety, and protocol-adherence requirements.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed