Population Health Coach RN

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. This contributes to the high quality of care our patients have come to expect.

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, you will manage chronic diseases through education, oversee referral patterns based on quality and patient experience, interpret performance data to develop workflows, and implement Evidence-Based Metric (EBM) guidelines, ensuring seamless transitions of care across settings.

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.

• Care Coordination: identify and coordinate referrals to team members via EMR, i.e. 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 no insurance or low income, and place referral to Prescription Assistance program (RxAP) and/or Social Work.
• 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
• 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

Required

• Associate Of Arts in Nursing and, upon hire and
• Advanced degree or 2 years relevant experience, upon hire and
• Registered Nurse: NE, upon hire

Preferred

• Bachelors Of Science of Nursing and 3 to 5 years experience, upon hire