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. Daily responsibilities include managing chronic diseases through education, overseeing referral patterns based on quality and patient experience, interpreting performance data to develop workflows, and implementing Evidence-Based Metric (EBM) guidelines. You will ensure seamless transitions of care across settings, with a strong focus on quality improvement and patient-centered care.

Responsibilities

• Care Coordination: Identify and coordinate referrals to team members via EMR, including 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 lack of insurance or low income and place referrals to the Prescription Assistance program (RxAP) and/or Social Work.
• Care Management and Outreach: Work with lists of patients in value-based contracts needing care gaps closed (e.g., annual wellness visits, colonoscopies, mammograms) and reach out to address these gaps. Identify participating patients in need of disease management and opportunities for preventative health interventions.
• New Diabetic Medication Starts: Provide education on new injectable medication, refer to Clinical Diabetes Education (CDE) for formal DM education, and continue follow-up.
• ED and Inpatient Discharge Alerts: Receive alerts via the Innovaccer platform notifying of patient discharges from the ED or Inpatient Unit. Use clinical judgment to determine whether 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.

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 a brand-new, fully modernized facility. The new 110,000-square-foot campus is better equipped to meet the changing needs of the community, with 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 patients expect.

Pay

$36.94 - $53.56 per hour