Role Summary: Drives measurable population health outcomes and medical/pharmacy cost optimization across Frontier’s highest-risk members. Operationalizes population health protocols, delivers concierge-level care coordination for complex case members, and prepares AI‑assisted medical case review packets for Medical Director sign‑off. Partner alongside and in close coordination with Frontier clinic staff for patient care, supports employer events, and leads high-touch outreach. This role emphasizes standards, checklists, and timeliness; it has functional (dotted‑line) oversight of queue work but no HR supervision.
Key Responsibilities
Population Health:
- Maintain protocolized HTN, DM, asthma, CKD, and lipid registries/queues.
- Ensure out‑of‑metric members are proactively contacted and scheduled for follow up visit
- Coordinate repeat biometric checks, home BP/glucose log reviews, standing lab orders, and medication titration follow-ups in partnership with Frontier PCPs until clinical markers reach target.
Complex Care Management:
- Manage an active cohort of complex/high-risk claimants with high-touch, concierge-level care coordination and longitudinal care plans.
- Conduct rapid post-discharge and post-visit follow-up calls within 24–48 hours of any ER visit, hospitalization, or specialist consultation to reconcile care plans, prevent readmissions, and close care gaps.
- Prepare concise, templated clinical pre-briefs (problem list, latest biomarkers, medication list, care gaps, owner, and due date) and participate in weekly Complex Case Conferences with the DPC+ Medical Director.
- Track weekly complex care action items to ensure >=90% closure within 7 calendar days and graduate stabilized patients back to standard primary care management.
- Coordinate with the patient the switch to alternative medication sourcing, preferred pharmacy routing, Patient Assistance Programs (PAPs), and manufacturer copay assistance to lower employer and member drug spend.
- Conduct 7-to-14-day post-medication standard kit list, consents, and post‑event reconciliation.
Documentation & Compliance:
- Maintain accurate, timely documentation of all patient encounters, outreach interactions, and treatments in the EHR.
- Follow all HIPAA, infection control, and clinic safety protocols, and maintain current licensure, certifications, and required clinical competencies.
Performance Bonus:
- You will be eligible for an annual performance bonus. Specific bonus amount, performance metrics, and payout structure will be determined by your manager and shared with you following your start date. Bonus criteria will generally align with your areas of responsibility, which may include case management, population health outreach, and team training and development. Any payout remains subject to standard quality, safety, and protocol-adherence requirements.
Qualifications
- Active, unrestricted Texas LVN or RN license in good standing with the Texas Board of Nursing (LVN/RN with 3+ years of case management, chronic disease management, or ambulatory/value-based care experience strongly preferred).
- Proven track record in high-touch patient care, motivational interviewing, and phone/SMS engagement with complex patients.
- Demonstrated ability to manage clinical registries and execute protocolized care pathways.
- Comfort using AI-assisted workflows to synthesize medical records and prepare clinical review packets (compiling clinical context for provider decision-making).
- Bilingual (English/Spanish) preferred.
Competencies
- Accuracy and follow‑through; pleasant, courteous member interaction; teamwork.
- Aligned to Frontier’s Foundational Four (SNAP): Smile & eye contact; Name the person; Attentive & present; Provide clear communication.
- No HR supervision duties; functional (dotted‑line) oversight of queue work only.
Physical Requirements
- Ability to sit, stand, and move throughout the clinic or office as needed.
- Ability to use standard office equipment, including computers, phones, and printers.
- Ability to occasionally lift or move up to 20 pounds.
Benefits - Taking Care of You Now and Your Future
- Medical, dental, and vision insurance.
- Frontier Membership for you and your immediate family.
- Voluntary insurance: short-term disability, long-term disability, life insurance, and other supplemental insurances.
- 401(k) plan: free access to financial wellness platforms that provide financial advisors + personal finance tools.
Time Off
- Paid time off policy, including up to 5 unplanned days off per year.
- 9 company holidays per year.
- Parental leave policies.
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