Job Description

RN - Patient Navigator - Clinic Population Health Nurse

Job Summary:

• The Patient Navigator/Clinic Population Health Nurse assumes responsibility and accountability for the management of resources through interdisciplinary collaboration to achieve optimal patient outcomes.
• The Navigator coordinates research data, community physicians, hospital resources into a seamless model of access and care benefiting patients, participating physicians, and family members.
• Identify and manage high-risk patient populations through assessment, outreach, and care coordination activities.
• 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 regarding 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 activities 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.

Qualifications/Experience:

• Associate Degree in Nursing (ADN) required; Bachelor of Science in Nursing (BSN) preferred.
• Graduation from an accredited nursing program approved by the Texas Board of Nursing or equivalent accredited institution
• 3 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 required.
• Must maintain licensure in good standing throughout employment.
• 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 preferred.
• Experience managing patients with chronic conditions such as diabetes, hypertension, heart disease, COPD, and behavioral health conditions preferred.
• Experience working with Medicare, Medicaid, managed care plans, and quality reporting programs preferred.
• Current AHA Basic Life Support (BLS) certification required.
• Case Management Certification (CCM), Ambulatory Care Nursing Certification (RN-BC), Public Health Nursing Certification, or similar certification preferred.
• Bilingual (English/Spanish) skills preferred.
• 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.

We are an equal opportunity employer and value diversity at our company. We do not discriminate based on race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.