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Population Health Coach RN

Company: Catholic Health Initiatives
Location: Lincoln
Posted on: May 28, 2023

Job Description:

Population Health Coach RN
Lincoln, Nebraska
CHI Health
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    Partnering for a stronger, healthier world.
    At CommonSpirit Health, we believe in the healing power of humanity. We invite you to explore our specialty areas and pursue a career in humankindness.


    • Employment Type: Full Time


    • Department: Population Health Management


    • Hours/Pay Period: 80


      The posted compensation range of $26.25 - $38.07 /hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.
      Requisition ID 2023-293690 Employment Type Full Time Hours/Pay Period 80 Shift Day Weekly Schedule Monday - Friday (8:00am - 5:00pm) Remote No Category Staff Nurse
      Already a CommonSpirit Employee? (https://www.commonspirit.careers/employee)
      Job Details
      Overview
      CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. & from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.
      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.


        Responsibilities
        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 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.


          Qualifications
          RN plus 5 years of experience in a related field required.Bachelor of Science or Masters of Science in Nursing preferred
          A 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
          Nursing excellence
          starts with you.
          Are you a career fit with our CommonSpirit Health culture? To understand how we are structured, we believe in some core philosophies with the following:
          We will be stronger together, achieving excellence in all we do, collaborating across the fields and growing our collective knowledge.
          We will let humankindness guide us as we treat every person with holistic, personalized care for the body, mind and spirit.
          We will advance the science and art of nursing as innovative leaders who demonstrate the power of evidence-based, compassionate care. If you believe in working together with humankindness for all to advance the science and art of nursing - then you have found your career fit with us!
          "Our hope is that you will always feel inspired, knowing you truly are the heart and soul of CommonSpirit."
          - Kathleen D. Sanford, EVP, Chief Nursing Officer
          Your Potential Career Path
          This is a snapshot of your potential career path highlights the series of job positions that help you progress towards your goals and objectives. Ultimately, your career path depends on your career values and personal goals.
          Success Profile
          What makes a successful Population Health Coach RN at CHI Health?


          • Compassionate


          • Trustworthy


          • Proactive


          • Collaborative


          • Communicator


          • Balanced


            Our Total Reward Offerings
            At CommonSpirit Health, your Total Rewards package includes compensation, benefits, retirement, wellness, leave, and other programs. Please explore what we have to offer below.
            Pay and Recognition
            Balanced Life
            Well-Being
            Professional Growth
            Financial Future
            Dependent Care
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              Equal Opportunity
              CommonSpirit Health--- is an Equal Opportunity/Affirmative Action employer committed to
              a diverse and inclusive workforce. All qualified applicants will be considered for
              employment without regard to race, color, religion, sex, sexual orientation, gender
              identity, national origin, age, disability, marital status, parental status,
              ancestry, veteran status, genetic information, or any other characteristic protected
              by law. For more information about your EEO rights as an applicant,
              pleaseclick here. (https://tbcdn.talentbrew.com/company/35300/img/v1_0/EEOC_KnowYourRightsEnglish.pdf)
              CommonSpirit Health--- will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c).
              External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
              If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA).
              CommonSpirit Health--- participates in E-Verify.

Keywords: Catholic Health Initiatives, Lincoln , Population Health Coach RN, Healthcare , Lincoln, Nebraska

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