Population Health Coach RN

Company: Dignity Health
Location: Lincoln
Posted on: August 5, 2022

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