Population Health Coach RN

About the Role

As our Population Health Coach RN, you will play a pivotal role in maintaining and improving the quality and sustainability of our clinically integrated network (CIN). By leveraging evidence-based metric (EBM) guidelines and data-driven workflows, you will bridge the gap between clinic, post-acute, and inpatient settings. You will serve as a vital clinical partner to physicians and staff, ensuring that our patient population receives high-quality, seamless, and patient-centered care while optimizing value-based performance outcomes.

Responsibilities

• Care Management & Outreach: Proactively manage high-risk patients and those with chronic diseases by closing clinical care gaps (such as annual wellness visits, colonoscopies, and mammograms) and facilitating necessary preventative health interventions.
• Seamless Care Transitions: Serve as a clinical bridge between acute, post-acute, and ambulatory care settings. This includes receiving and acting on ED/Inpatient discharge alerts to ensure smooth transitions and appropriate follow-up care for patients returning home.
• Interdisciplinary Care Coordination: Function as a central point of contact for the clinical team by coordinating referrals for social work, dieticians, prescription assistance, and diabetes education to ensure a holistic approach to patient health.
• Evidence-Based Practice Implementation: Apply and hardwire clinical evidence-based metric (EBM) guidelines within the clinic setting to improve overall quality of care and patient experience outcomes.
• Clinical Performance Tracking: Utilize information technology and data platforms (such as Innovaccer) to monitor workflows, track patient status, and report on care effectiveness to support the quality and sustainability of the clinically integrated network.

Requirements

• Associate Degree in Nursing (Required)
• Bachelor's Degree in Nursing (Preferred)
• Minimum of 2 years of nursing experience required; 3–5 years preferred
• Current Nebraska (NE) Registered Nurse license required (Compact accepted)

Pay

$36.94 - $53.56 /hour