Licensed Nurse Care Coordinator Senior - Population Health Job at CHRISTUS Health (Irving)

Licensed Nurse Care Coordinator Senior - Population Health

CHRISTUS Health

Location:
United States , Irving

Category:
Nursing

Contract Type:
Not provided

Salary:

Not provided

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Job Description:

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuity of services. The Care Coordinator is responsible for making telephonic outreaches to members attributed to our value-based contacts. They support the ACO and CIN network providers and practices in successfully meeting quality improvement initiatives, monitoring standards of care and managing high risk multi morbidity patient populations across CHRISTUS Health ministries. The role focuses on improving quality care gaps, promoting preventive care, and improving patient outcomes.

Job Responsibility:

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Mentor, train and support the team of care coordinators, ensuring high-quality care and adherence to best practices
Assist with work assignments and development of new work processes as needed
Coordinate and assist with associate onboarding
Create education material for training
Monitor and ensure compliance with all regulatory requirements, organizational policies, standing delegated orders and protocols
Identify quality gaps and risk adjustment gaps
Participate in Quality Improvement Programs as indicated
Attend learning sessions and share information learned with team members
Assist in the development of tools, education, and workflow processes to assist the network in meeting CMS, ACO, documentation, and payor quality initiatives
Conducts internal review audits to facilitate feedback for documentation and efficiency of the care coordination team
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments
Maintain ongoing communication with healthcare providers through various tools and meetings
Monitor value-based care quality performance and pulls reports to identify open care gaps
Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance
Providing counseling and health education to patients and families, using appropriate materials and standardized protocols
Serve as a subject matter expert in care transitions & quality metrics
Assist in educating practice staff on quality, payor, and government program requirements
Communicate resources and services available to patients through the continuum of care
Escalate health concerns to Primary Care providers and place referrals to appropriate care team members, i.e., Nurse Navigation, CHW, etc
Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness
Conduct in-person and virtual meetings with practice managers, staff, providers and managers to communicate program goals, results, and provide education
Document relevant, comprehensive information and data using standard assessment tools
Maintain patient chart compliance through proper documentation and updated: preventative screenings, medical history, medication, and immunizations
Unburden primary care providers by placing approved orders for labs and other screenings as per the Standing Delegated orders
Perform Transition of Care calls on patients transitioning from an inpatient stay to home, or emergency department encounter to identify the need for a follow-up appointment, community resource needs, scheduling follow-up appointments, reviewing discharge instructions, and medications
Utilizing clinical judgment and problem-solving skills to coordinate appropriate care with physicians and Nurse Navigation
Prepare and maintain Transitions of Care and Care Management reports and provide periodic updates to network leaders
Must have strong leadership, exceptional oral communication skills, strong organizational and analytical skills, ability to adapt to change and motivate a team
Must have a strong ability to multi-task and coordinate multiple projects
Perform other duties as assigned

Requirements:

High School Diploma required
Minimum of 3 years of clinical or home health experience required
5 years supporting value-based care programs, accountable care organizations, or HEDIS
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred
Knowledge of physician office practice operations and 3 years of experience in a physician practice is preferred
Proficiency in keyboarding and EHR systems, primarily Epic
LVN/ LPN in the state of employment and/or compact licensure required

Nice to have:

Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives
Knowledge of physician office practice operations and 3 years of experience in a physician practice

Additional Information:

Job Posted:
February 05, 2026

Employment Type:

Fulltime

Work Type:

On-site work

CHRISTUS Health - All Job Offers

Job Link Share:

Licensed Nurse Care Coordinator Senior - Population Health

CHRISTUS Health

Location:
United States , Irving

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 05, 2026

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