Population Health Coach RN

CHI Health St. Mary’s has served Nebraska City and the surrounding areas since 1927. In the fall of 2014 St. Mary’s opened the doors of a brand-new fully modernized facility. The new 110000-square-foot campus is better equipped to meet the changing needs of our community with among other benefits an increased capacity for specialty clinics and an integrated primary care clinic. St. Mary’s encourages collaboration and care coordination among primary care physicians and medical specialists. This contributes to the high quality of care our patients have come to expect.

With guidance from CHI Health Partners’ President, Medical Directors, and Division Manager of Ambulatory Care Management, works collaboratively with physicians, staff and other health care professionals within his/her clinically integrated network (CIN), CHI Health Partners, to maintain and improve quality and sustainability within the CIN.

• Care Coordination: identify and coordinate referrals to team members via EMR, i.e. MSW, dietician, Prescription Assistance team, and Certified Diabetic Educators.

• Clinic Referrals: receive referrals from providers/staff via EMR or face-to-face clinic settings.

• Prescription Assistance and Financial Assistance Program Referrals: identify patients in need due to no insurance or low income, and place referral to Prescription Assistance program (RxAP) and/or Social Work.

• Care Management and Outreach to high risk patients and those with chronic disease: lists will be sent out of patients in our value-based contracts needing care gaps closed, i.e. annual wellness visits, colonoscopies, mammograms, etc. and the PHC will need to reach out to try to close these gaps. Identify participating patients in need of disease management and opportunities for preventative health interventions

• New Diabetic Medication Starts: education on new injectable medication and referral to Clinical Diabetes Education (CDE) for formal DM education and continued follow up

• ED and Inpatient Discharge Alerts: PHC will receive alerts via Innovaccer platform notifying him/her that a patient attributed to his/her clinic was discharged from the ED or Inpatient Unit. PHC will use clinical judgment as to whether outreach is warranted

• Communication/Care Coordination with hospital, SNF and other healthcare professionals: maintain open communication with inpatient care management staff and SNF population health coaches to ensure a smooth transition from acute and post-acute settings to home and timely and appropriate follow up care. Ensure care handoff between levels of care is seamless. Collaborate with other members of healthcare team to include, but not limited to staff from ED, IP, SNF, HHC, palliative care, area office on aging, community health workers, etc.

Required:

RN plus 5 years of experience in a related field required. Bachelor of Science or Masters of Science in Nursing preferred

A current unencumbered RN license to practice in the State of Nebraska. Certification as Healthcare Coach or obtained within two years of hire.
Experience: Five years of clinical and case management/nursing education/quality improvement experience.
Clinic/Physician office, home care, public health and/or social service experience preferred.

Preferred:

Experience in patient education.