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Work Schedule/Shift


Job ID


Req. No


Job Title

Manager Population Health


Not Defined


Registered Nurse (RN)


Not Defined






TMFHS Woodgate IV Bldg-38050


1315 Doctors Dr
Tyler, TX  75701


Full Time

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The Nurse Manager of Population Health is responsible for the leadership of the Population Health clinical team. This role has direct responsibility for managing, coordinating, and evaluating Care Coordination and Management Services and product offerings. This position will collaborate with the Population Health Physician Lead, Administrative Director, Associate Chief Nursing Officer and other clinical and administrative stakeholders to manage care for targeted populations to improve patient health, quality and cost outcomes based on current evidenced-based practice, adheres to regulations set by regulatory agencies, and maintains contract compliance.

  • Provides supervision and management of the clinical staff in the Population Health department.
  • Maintains and ensures the confidentiality of all Personal Health Information (PHI) collected
  • Provides clinical guidance and supervision of Population Health Program Initiatives based on accepted principles of nursing and Care Management practice; as well as PCMH principles.
  • Works in collaboration with the Population Health Physician Lead and other Clinical and Administrative Leadership to develop and implement program initiatives to achieve organizational objectives.
  • Partners with the system and health plans to develop/share and implement strategies for improving transitions of care, case management handoffs, chronic disease care, and preventive services as well as after-hours medical service.
  • Manages team to work collaboratively with primary and specialty providers, patients and caregivers, Health Specialists, Health Educators, Navigators, clinical staff and community agencies to link patients to needed preventative health services to prevent illness, improve skills for self-management of chronic conditions, and promote healthy lifestyle behavior change.
  • Supervises activities of team who outreach to patients identified via primary care practices for evidence-based programs and services including breast and colorectal cancer screening, diabetes prevention, and chronic disease management.
  • Assists team with assessing patients' needs, problem solving with team, and moving patients through the continuum of care.
  • Determines educational needs and facilitates ongoing professional development of clinical staff by mentoring, training, and implementing processes to increase the patient experience and efficiency in conjunction with operational leadership. Ensures that nursing staff are current in competencies, assessments, licensure, certifications, and other annual training.
  • Identifies opportunities to improve clinical care, customer service and internal business processes.
  • Collects, reports, trends and analyzes Population Health Program data for departmental productivity and performance outcome reporting.
  • Validates quality audit results for accuracy and individual developmental needs within Program.
  • Formulates, implements, adheres and evaluates clinical support plans/policies, goals and objectives that are consistent with the hospital and clinics mission/vision, goals, contracts policies, procedures, and regulatory agencies.
  • Act as a liaison between the acute care setting and the post-acute care settings, facilitating transitional care activities.
  • Acts as a resource to ensure effective communication between acute and post-acute settings, in an effort to prevent unnecessary re-admissions back to the acute setting.
  • Develops staff performance objectives based on identified improvement or developmental opportunities and aligns with organizational performance outcome objectives.
  • Demonstrates a strong commitment to the mission and values of CHRISTUS.
  • Performs other duties as assigned.
  • Bachelor's Degree in Nursing required/Master's Degree in Nursing or related field preferred.
  • Skills in critical thinking and problem solving to identify and implement new care delivery models.
  • Proficiency in interpretation and representation of clinical data. Ability to support the rapid adoption of national patient-centered care best practices and support timely implementation.
  • Understanding of transitional care principles and regulatory requirements.
  • Skills in establishing excellent working relationships and strategic collaborating with various internal and external teams, departments, and groups.
  • Understanding of health care delivery and health care dynamics.
  • Skills in managing multiple, conflicting, complex demands in geographically dispersed areas.
  • Leadership and change management skills.
  • Excellent written and verbal communication skills and the ability to communicate effectively with all levels of employees.
  • Experience working with diverse nursing groups on a variety of clinical, care management, and quality related projects.
    • Required Functional Experience:

    Requires 5 years of experience in working in clinical programs and in implementing service oriented and patient centered care philosophies and strategies.

    • Required Management Experience:

    Includes 3 years of management experience in management of staff, budgets and multiple functional areas at the manager level.

  • Texas Registered Nurse license required.
  • Must obtain National certification in area of clinical specialty or Leadership within 3 years.
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