Population Health Nurse Coordinator (RN/LVN)

Frontier Direct Care, LLC; Harlingen (TX); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

Frontier Membership for you and family

Voluntary disability and life ins.

401(k) plan with financial tools

Job summary

Frontier Direct Care, LLC in Texas seeks an LVN/RN with population health experience to drive outcomes and coordinate complex care. You will partner with clinic staff, support employer events, and lead high-touch outreach while ensuring compliance and timely care delivery.

The role emphasizes standardized protocols, checklists, and AI-assisted workflows to optimize care and costs. A performance bonus is available and licensure must be in good standing in Texas.

Qualifications

• Active, unrestricted Texas LVN or RN license in good standing.
• 3+ years of case management, chronic disease management, or ambulatory/value-based care experience preferred.
• Bilingual English/Spanish preferred.

Responsibilities

• Maintain protocolized HTN, DM, asthma, CKD, and lipid registries/queues.
• Manage an active cohort of complex/high-risk claimants with concierge-level care coordination and longitudinal care plans.
• Conduct rapid post-discharge and post-visit follow-up calls within 24–48 hours of ER visits or hospitalizations to reconcile care plans and prevent readmissions.
• Prepare templated clinical pre-briefs and participate in weekly Complex Case Conferences.
• Track weekly action items to ensure 90% closure within 7 days and transition patients to standard primary care.
• Coordinate medication sourcing, PAPs, and manufacturer copay assistance to lower drug spend.

Skills

High-touch patient care

Motivational interviewing

Phone/SMS engagement

Education

Active Texas LVN or RN license

Tools

EHR system

AI-assisted workflows

Job description

Frontier Direct Care, LLC in Texas seeks an LVN/RN with population health experience to drive outcomes and coordinate complex care. You will partner with clinic staff, support employer events, and lead high-touch outreach while ensuring compliance and timely care delivery.

The role emphasizes standardized protocols, checklists, and AI-assisted workflows to optimize care and costs. A performance bonus is available and licensure must be in good standing in Texas.