Population Health Coach RN
Company: Dignity Health
Location: Lincoln
Posted on: August 5, 2022
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Job Description:
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-EducatorPractice Pattern Management-Referral Management,
based on Quality of Care, CHI Health Partners (clinically
integrated network), and patient experience.Performance Data
Interpretation-Develops and audits workflowsEvidence-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.ResponsibilitiesCare 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 interventionsNew Diabetic
Medication Starts: education on new injectable medication and
referral to Clinical Diabetes Education (CDE) for formal DM
education and continued follow upED 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 warrantedCommunication/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
managementRN plus 5 years of experience in a related field
required. Bachelor of Science or Masters of Science in Nursing
preferredA current RN license to practice in the State of Nebraska
is required. Certification as Healthcare Coach or obtained within
two years of hire.Experience: 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
Keywords: Dignity Health, Lincoln , Population Health Coach RN, Healthcare , Lincoln, Nebraska
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