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

• Facilitate comprehensive care coordination by managing clinical referrals, monitoring high-risk patient populations, and closing critical care gaps such as annual wellness visits and preventative screenings.
• Utilize the Innovaccer platform to conduct timely outreach for patients discharged from ED or inpatient units, provide education on new diabetic medications, and connect vulnerable patients with essential financial and prescription assistance programs.
• Foster collaboration across the healthcare continuum—including social work, dieticians, and home health teams—to guarantee smooth transitions and improved health outcomes.
• 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.
• Serve as a clinical bridge between acute, post-acute, and ambulatory care settings, including receiving and acting on ED/Inpatient discharge alerts to ensure smooth transitions and appropriate follow-up care for patients returning home.
• 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.
• Apply and hardwire clinical evidence-based metric (EBM) guidelines within the clinic setting to improve overall quality of care and patient experience outcomes.
• 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.

Qualifications

• 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).

Skills

• Strong organizational and time-management skills with the ability to work autonomously in a complex matrix environment.
• Proficiency in EMR systems and Microsoft Office.
• Deep understanding of information technology used to evaluate care effectiveness.
• Ability to communicate effectively with interdisciplinary teams, handle multiple clinical priorities with precision, and adapt to evolving program goals.

Benefits

• Up to $5,000 Sign-on Bonus for eligible new hires.
• Up to $10,000 Educational Assistance for eligible new hires.

Pay

$36.94 - $53.56 /hour

Schedule

Full-time position at CHI Health Schuyler, serving the communities of Schuyler, Clarkson, Howells, Leigh and the residents of rural Colfax County in Nebraska. The facility is a 25-bed critical access hospital offering a wide variety of services to residents of all ages.