CHI Health Hiring For Population Health Coach Rn at Bellevue, NE, United States Full Time

Job Description

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.

Responsibilities

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.

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

Qualifications

RN plus 5 years of experience in a related field required. Bachelor of Science or Masters of Science in Nursing preferred
A current unencumbered 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
Skills: Must have strong organizational (time management) skills, strong interpersonal skills
and the ability to handle multiple priorities. Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word. Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost) for individual users of health care and patient populations. Exhibits professionalism and ability to build rapport and maintain relationships with providers.

CommonSpirit Health participates in E-verify.