Hunt Memorial Hospital District

Population Health Nurse

1 week ago
Job ID
# Positions
M-F flex


The objective of population health nurse is to coordinate team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. The population health nurse facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient- and family-centered.


  1. Provide a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population.
  2. Implement an effective internal tracking system for identified patients, including the use of the EHR system utilized.
  3. Coach patients/families toward successful self-management of their chronic disease.
  4. Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.
  5. Assess patient and family’s unmet health and social needs.
  6. Provide effective communications for patients and staff members to improve health literacy.
  7. Develop a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
  8. Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
  9. Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
  10. Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator).
  11. Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
  12. Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
  13. Ensure effective tracking mechanism for receipt of test results, medication management, and adherence to follow-up appointments.
  14. Develop systems to reduce and prevent errors (e.g., effective medication reconciliation and shared medical records) with trainings, informational teachings, monitoring system(s) and providing feedback to improve patient safety.
  15. Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed.
  16. Attend and actively participate in all Accountable Care Organization and Care Coordination related training and meeting activities.


Required: Graduate from an accredited school or college of nursing.

Required: Current Texas Registered Nurse licensure.



  1. Required: two years in acute care nursing position.
  2. Preferred: Demonstrates knowledge of Standard of Nursing Practice Act, nursing process, medical necessity criteria and principals of management/leadership.
  3. Demonstrates knowledge of quality and performance improvement principals



    1. Effective written and verbal communication and negotiating skills with all levels of internal and external stakeholders.
    2. Must demonstrate positive relationship building with patients, peers, medical staff, and other members of the clinical care team.
    3. Must demonstrate the ability to effectively implement changes.
    4. Must demonstrate collaborative approach to problem solving and communication as a team-member.


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