RN Health Coach

4 weeks ago

Omaha, Nebraska, United States Catholic Health Initiatives Full time

Care for patients with compassion and expertise as a Population Health Coach RN at Catholic Health Initiatives. Collaborate with physicians, staff, and other healthcare professionals to maintain and improve quality and sustainability within our clinically integrated network, CHI Health Partners.

Key Responsibilities:

  • 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.
  • Care Coordination :
    • Identify and coordinate referrals to team members via EMR, i.e. MSW, dietician, Prescription Assistance team, and Certified Diabetic Educators.
    • Receive referrals from providers/staff via EMR or face-to-face clinic settings.
    • 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. 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.

Requirements:

  • Bachelor of Science or Masters of Science in Nursing preferred.
  • Certification as a Healthcare Coach OR must obtain within 2 years of hire.

Catholic Health Initiatives offers a comprehensive benefits package, including Health/Dental/Vision Insurance, Direct Primary Plan, Employee Assistance Program, Matching 401(k) and 457(b) Retirement Programs, Adoption Assistance, and Flexible spending accounts. Join our team and be part of a mission-driven organization that cares for patients and their families with compassion and expertise.

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