Population Health Nurse

Hunt Regional Healthcare Greenville, TX
  • Depends on experience
  • Full Time
  • Employer Likely to Respond

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 provider. 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. Facilitate Medicare Annual Wellness Visit, Quality Measure performance, Hierarchical Categorical Condition, and Chronic Care Management referral achievement at the practice level.
  2. Communicate practice-level quality measure performance results to the individual provider and practice.
  3. Provide a coordinated, strategic approach to effectively manage the chronically ill patient population.
  4. Provide a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population.
  5. Coach patients/families toward successful self-management of their chronic disease.
  6. Utilize tools that support a guided care process, collaborate with patient/family toward an effective plan of care.
  7. Assess patient and family’s unmet health and social needs.
  8. Provide effective communication for patients and staff members to improve health literacy.
  9. 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.
  10. Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
  11. Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
  12. Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists.
  13. 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.
  14. Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
  15. Ensure effective tracking mechanism for receipt of test results, medication management, and adherence to follow-up appointments.
  16. Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed.
  17. Attend and actively participate in all Accountable Care Organization and Care Coordination related training and meeting activities.
  18. Identify patients who have deficient or past due health screenings, call patients to obtain health screening documentation or telephonically perform and document the health screening. 

The above statement reflect the general duties considered necessary to describe the principal functions of the job as identified, and shall not be considered as a detailed description of all of the work requirements inherent in the position.


  1. Required: Graduate from an accredited school or college of nursing. 
  2. 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

Our Culture

Would you like to have a positive influence on the lives of patients and families in Hunt County, Texas? With a career at Hunt Regional Healthcare, you’ll have that chance.

As a member of our team, you’ll have the opportunity to live out our mission and vision through service-oriented care. Hunt Regional aims to be the preferred health care system in the communities and surrounding areas we serve. We do that through state-of-the-art technology, continually advancing service lines, and through providing a safe healing environment and outstanding patient experience for each individual we treat. Our values and quality care set our organization apart.

Our Benefits

Hunt Regional Healthcare is proud to offer a competitive benefits package that is designed to work for you. If you're looking for premium healthcare coverage, you've come to the right organization.

Core benefits include:

  • Medical benefits
  • Dental & vision benefits
  • Long-term disability
  • Voluntary accidental death & dismemberment
  • Life insurance 

We also provide a robust supplementary benefits package, including:

  • Prescription coverage
  • Wellness perks
  • Employee counseling
  • Retirement packages
  • Flexible spending accounts
  • Paid vacation time off
  • Generous sick leave allowance
  • Other voluntary benefits
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