Population Health Nurse

Job description

Become a part of our caring community 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. Population Health & Care Transitions: · Lead proactive identification and outreach for high-risk patients, with emphasis on: · Out-...