Population Health Nurse

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-of-network hospital admissions

·       Patients at risk for inpatient, observation, or ED utilization

·       ESRD and advanced CKD (Stages 4–5) populations

·       Provide end-to-end transitions of care support, including inpatient, ED, observation, and post-acute transitions.

·       Conduct goals of care conversations and provide support for palliative and hospice care discussions

·       Conduct post-discharge follow-up aligned with Transitional Care Management (TCM) requirements to reduce avoidable readmissions and ED returns.

Out-of-Network Hospitalization Management

·       Identify and track OON admissions using EMR and utilization data.

·       Partner with providers, care teams, and leadership to intervene early and address drivers of OON utilization.

·       Support care continuity post-discharge, including medication reconciliation, follow-up scheduling, and specialist coordination.

·       Escalate systemic barriers impacting network alignment, access, or care coordination to the MCMO and market leadership.

·       Provide education to patients on in-network hospitals and call us first services

Kidney Care Navigation & Chronic Disease Support

·       Serve as a clinical navigator for patients with ESRD and CKD Stages 4–5.

·       Collaborate with dialysis centers to ensure completion and submission of CMS Form 2728  for ESRD patients

·       Conduct comprehensive assessments to understand clinical, social, and system-level needs.

·       Collaborate with PCPs, nephrologists, and interdisciplinary teams to support individualized care plans.

·       Educate patients and caregivers on disease progression, treatment options, self-management, and care planning.

Quality, Data & Value-Based Performance

·       Analyze clinical and utilization data to identify trends and care gaps related to:

·       Medicare Advantage Stars

·       HEDIS

·       Utilization and avoidable admissions

·       Prioritize interventions that improve quality performance, affordability, and patient outcomes.

·       Support accurate documentation, coding, and care gap closure in partnership with providers and clinic teams.

Collaboration & Program Development

·       Work closely with physicians, clinic staff, pharmacy, care assistants, and quality teams to implement evidence-based interventions.

·       Participate in huddles, high-risk rounds, and case conferences.

·       Contribute to the development and refinement of population health workflows, particularly for kidney care and hospitalization management.

·       Provide informal education and clinical support to care teams related to population health priorities

·       Coordinate with Integrated Home Care Program and CW Home Health to reduce unnecessary hospital utilization

Documentation & Compliance

·       Document patient outreach, assessments, interventions, and outcomes accurately and timely in the medical record.

·       Ensure compliance with HIPAA, CMS requirements, and organizational policies.

·       Maintain confidentiality, safety standards, and professional conduct.

Use your skills to make an impact
 

Required Qualifications

 

Active, unrestricted Registered Nurse (RN) license in the state of practice.

Associate’s or Bachelor’s degree in Nursing (ADN or BSN).

3+ years of clinical nursing experience, with exposure to one or more of the following:

Transitions of care

Population health or care management

Chronic disease management

Hospital, post-acute, or managed care environments

Strong clinical judgment, critical thinking, and care coordination skills.

Proficiency with EMR systems and basic data analysis tools.

Ability to work independently while collaborating effectively across teams.

 

Preferred Qualifications

 

5+ years of experience in population health, care management, nephrology, dialysis, or complex care navigation.

Experience with ESRD and advanced CKD populations.

Experience with utilization management and hospital transitions, including post-discharge follow-up.

Knowledge of Medicare Advantage, Stars, HEDIS, and value-based care models.

Certification in Case Management (CCM) and/or Nephrology Nursing (CNN).

Experience in program development or workflow design.

Bilingual proficiency (market dependent).

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Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

 

$78,200 - $107,600 per year

 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us
 About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being.

About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com.

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Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.