RN - Patient Navigator - Clinic Population Health Nurse- PRN

Odessa Regional Medical Center•Odessa, TX

26d

About The Position

The Patient Navigator/Clinic Population Health Nurse is accountable for managing resources through interdisciplinary collaboration to achieve optimal patient outcomes. The role coordinates research data, community physicians, and hospital resources to create a seamless model of access and care for patients, participating physicians, and family members. The nurse identifies and manages high-risk patient populations through assessment, outreach, and care coordination. The role monitors patient registries and population health reports, coordinates care transitions and follow-up services, and collaborates with clinical and interdisciplinary teams to develop patient-centered care plans. Outreach may be conducted by telephone, virtually, or in person to support chronic disease management and preventive care. The role also provides patient and family education, facilitates referrals, supports quality improvement and value-based care initiatives, tracks interventions and outcomes in the electronic health record, analyzes population health data, and helps address barriers to care. The nurse participates in team meetings, case reviews, and quality improvement projects while maintaining compliance with organizational policies, regulatory requirements, nursing standards, and HIPAA guidelines.

Requirements

Associate Degree in Nursing (ADN) required.
Graduation from an accredited nursing program approved by the Texas Board of Nursing or an equivalent accredited institution.
Three years of experience in patient education, nursing, planning, case management, or similar experience.
Current, active, unrestricted Registered Nurse (RN) license in the State of Texas; licensure must remain in good standing throughout employment.
Current AHA Basic Life Support (BLS) certification required.
Experience in federally qualified health centers (FQHCs), physician practices, health systems, managed care organizations, or community-based healthcare settings.
Experience with care gap closure initiatives, risk adjustment, and quality improvement programs.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Previous experience in population health, care management, case management, utilization management, quality improvement, ambulatory care, primary care, accountable care organizations (ACO), or value-based care.
Experience managing patients with chronic conditions such as diabetes, hypertension, heart disease, COPD, and behavioral health conditions.
Experience working with Medicare, Medicaid, managed care plans, and quality reporting programs.
Case Management Certification (CCM), Ambulatory Care Nursing Certification (RN-BC), Public Health Nursing Certification, or similar certification.
Bilingual English/Spanish skills.

Responsibilities

Identify and manage high-risk patient populations through assessment, outreach, and care coordination.
Monitor patient registries and population health reports to identify care gaps, overdue screenings, and opportunities for intervention.
Coordinate care transitions and follow-up services for patients discharged from hospitals, emergency departments, and skilled nursing facilities.
Collaborate with physicians, advanced practice providers, care managers, and interdisciplinary teams to develop and implement patient-centered care plans.
Conduct telephonic, virtual, and in-person patient outreach to support chronic disease management and preventive care compliance.
Educate patients and families about disease processes, medications, treatment plans, lifestyle modifications, and self-management strategies.
Facilitate referrals to specialists, community resources, social services, and support programs as appropriate.
Review clinical quality measures and assist with initiatives to improve organizational performance related to value-based care programs.
Track and document interventions, outcomes, and patient interactions within the electronic health record (EHR).
Assist in closing quality gaps related to preventive screenings, immunizations, chronic disease management, and regulatory requirements.
Analyze population health data and trends to support quality improvement and care management initiatives.
Monitor patient adherence to treatment plans and coordinate interventions to reduce barriers to care.
Support risk stratification and identification of patients requiring enhanced care management services.
Participate in multidisciplinary team meetings, case reviews, and quality improvement projects.
Ensure compliance with organizational policies, regulatory requirements, and nursing standards of practice.
Maintain patient confidentiality and adhere to HIPAA guidelines.
Perform other duties as assigned to support population health, quality, and care management objectives.