Population Health Coach RN

About the role

As a Population Health Coach, you will collaborate with physicians, staff, and healthcare professionals within your clinically integrated network to enhance quality and sustainability. Success in this role requires a strong grasp of population health, excellent collaboration, data analysis skills, and a commitment to quality improvement and patient-centered care.

Responsibilities

• Manage chronic diseases through education and outreach.
• Oversee referral patterns based on quality and patient experience.
• Interpret performance data to develop workflows and implement Evidence-Based Metric (EBM) guidelines.
• Ensure seamless transitions of care across settings.
• Coordinate referrals to team members via EMR, including 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 of prescription or financial assistance and place referrals to Prescription Assistance Program (RxAP) and/or Social Work.
• Manage care and outreach to high-risk patients and those with chronic disease by closing care gaps (e.g., annual wellness visits, colonoscopies, mammograms).
• Identify participating patients in need of disease management and opportunities for preventative health interventions.
• Provide education on new injectable diabetic medications and refer patients to Clinical Diabetes Education (CDE) for formal DM education and continued follow-up.
• Respond to ED and Inpatient discharge alerts via the Innovaccer platform, using clinical judgment to determine if outreach is warranted.

Requirements

• Required Associate of Arts in Nursing and, upon hire, an advanced degree or 2 years of relevant experience.
• Required Registered Nurse license in Nebraska, upon hire.
• Preferred Bachelor of Science in Nursing and 3 to 5 years of experience, upon hire.

Where You'll Work

CHI Health St. Mary’s has served Nebraska City and the surrounding areas since 1927. In the fall of 2014, St. Mary’s opened the doors of a brand-new, fully modernized facility. The new 110,000-square-foot campus is better equipped to meet the changing needs of our community with, among other benefits, an increased capacity for specialty clinics and an integrated primary care clinic. St. Mary’s encourages collaboration and care coordination among primary care physicians and medical specialists, contributing to the high quality of care our patients have come to expect.

Pay

$36.94 - $53.56 /hour