population health coach rn - Papillion, NE , USA, United States - Common Spirit

Common Spirit Papillion, NE , USA, United States

3 days ago

Description

Overview

From primary to specialty care as well as walk-in and virtual services CHI Health Clinic delivers more options and better access so you can spend time on what matters: being healthy.

We offer more than 20 specialties and 100 convenient locations; with some clinics offering extended hours.

CHI Health would love to add a Population Health Coach RN (Nurse) to our team located at our Midlands Location off of Hwy 370 & 84th St in Papillion

Hours:
Monday-Friday 8a-5p, NO weekends, NO holidays & NO call

CHI Health strives to care for you the way you care for your patients.

We understand you have personal responsibilities outside of your profession and also care about your well-being.

With you in mind, we offer the following benefits to support your work/life balance:

Health/Dental/Vision Insurance
Direct Primary Plan (No copay, no deductible, and access to CHI Health provider 24/7)
Voluntary Protection: Group Accident, Critical Illness, and Identity Theft
Employee Assistance Program (EAP) for you and your family
Paid Time Off (PTO)
Tuition Assistance for career growth and development
Matching 401(k) and 457(b) Retirement Programs
Adoption Assistance
Wellness Programs
Flexible spending accounts

CHI Health, now part of CommonSpirit Health formed between Catholic Health Initiatives (CHI) and Dignity Health, includes 150+ clinics delivering quality care to patients across Nebraska and southeast Iowa.

Our full-service network provides a variety of Primary Care & Priority Care Services, including Family, Internal, Geriatric, and Pediatric Medicine, in addition to several specialties to deliver custom care based on the unique needs of our patients.

Responsibilities

$5000 Sign On Bonus Offered

Paid out in FULL after 30 days of employment

Job Summary / Purpose

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

Includes:

Chronic Disease Management-Educator
Practice Pattern Management-Referral Management, based on Quality of Care, CHI Health Partners (clinically integrated network), and patient experience.
Performance Data Interpretation-Develops and audits workflows
Evidence-Based Metric (EBM) guidelines-Implements and hardwires different EBM guidelines in the clinic setting as well as facilitating seamless transitions of care between clinic and post-acute settings and between clinic and other health professionals.

Essential Key Job Responsibilities

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.
Other duties as assigned by management

Qualifications

Minimum Qualifications:

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

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