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Population Health Nurse

CenterWell Home Health · League City, TX Full Time

$78200 – $107600 / year

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Job Description

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 c

This is a preview of the job listing. The full posting includes complete compensation details, benefits package, qualification requirements, and application instructions.

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What Most Job Listings Don’t Tell You

General overview for this role type — specific duties and requirements vary by employer.

Support roles in senior living — housekeeping, maintenance, activities, and social work — are far more resident-facing than similar positions in other industries. Housekeepers and maintenance staff interact with residents in their personal living spaces daily, which requires discretion, patience, and genuine respect for the people who live there. In Texas, even non-clinical staff must complete facility-specific training on topics like abuse prevention, infection control, and emergency procedures.

Activities coordinators and social workers play a direct role in resident well-being — isolation and depression are significant concerns in senior living, and programming that keeps residents socially engaged has measurable health outcomes. Maintenance staff in senior care need to understand life-safety systems (fire alarms, emergency generators, call systems) and are often the first responders for building emergencies. Background checks are required for all positions, and many facilities prefer candidates who have previous experience working with older adults.

What to Expect in This Role Day-to-Day

Based on typical senior living facilities in the Houston area.

For housekeeping roles, the day follows a room-by-room schedule — cleaning resident rooms, sanitizing common areas, managing laundry, and responding to spill or accident cleanups as they happen. Infection control protocols are more rigorous than in hotels or commercial cleaning, especially during flu season or respiratory illness outbreaks.

Maintenance staff handle a daily work order queue — everything from changing light bulbs and fixing call buttons to HVAC maintenance and plumbing repairs. Life-safety equipment checks (fire extinguishers, exit lighting, generator testing) happen on set schedules. Activities professionals plan and lead group programming — exercise classes, crafts, music sessions, outings — and also provide one-on-one engagement for residents who cannot participate in group settings. Social workers manage care conferences, discharge planning, family mediation, and community resource referrals. Across all these roles, the common thread is that you become a familiar, trusted presence in residents' daily lives.

About This Employer

CenterWell Home Health is a Parent Agency located in League City, TX at 3027 Marina Bay Drive, Suite 107. This facility holds a 4.6-star Google rating based on 24 reviews.

Care services offered: Licensed And Certified Home Health Services; Licensed Home Health Services

View Full CenterWell Home Health Profile → See all openings at CenterWell Home Health →

Employer profile provided by Houston Senior Living Guide

Houston Area Salary Data

According to the Bureau of Labor Statistics, Home Health and Personal Care Aide positions in the Houston metro area earn a median wage of $10.97/hr ($22,818/yr). The typical range is $10.60 – $13.28/hr (25th–75th percentile).

Entry Level (10th) $20,613/yr

Houston Median $22,818/yr

Experienced (90th) $30,597/yr

vs. National Median -34.6%

Source: Bureau of Labor Statistics, Occupational Employment & Wage Statistics (Houston-Pasadena-The Woodlands, TX Metro Area). Salary data provided by Houston Senior Living Guide.