Population Health Coach RN
4 days ago
CHI Health is seeking a Population Health Coach RN to join our team. As a key member of our clinically integrated network, you will work collaboratively with physicians, staff, and other healthcare professionals to maintain and improve quality and sustainability within the network.
Responsibilities- Chronic Disease Management-Educator: Provide education to patients with chronic diseases to help them manage their conditions and improve their health outcomes.
- Practice Pattern Management-Referral Management: Manage referrals to team members via EMR, i.e. MSW, dietician, Prescription Assistance team, and Certified Diabetic Educators.
- Performance Data Interpretation: Develop and audit workflows to ensure quality and sustainability within the network.
- Evidence-Based Metric (EBM) guidelines: Implement and hardwire 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.
- 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.
- Bachelor of Science or Masters of Science in Nursing preferred.
- 5 Years of RN experience in the Clinical setting strongly preferred.
- Active state RN license required.
- Certification as a Healthcare Coach OR must obtain within 2 years of hire.
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