High Risk Health Coach RN

Trinity Health•Des Moines, IA

1d•Remote

About The Position

The RN Ambulatory Health Coach provides care management and care coordination services to Population Health patients with complex illnesses residing in the community setting. This includes managing a panel of high-acuity patients, managing their transitions in care across the care continuum, and providing coaching and education to support patient self-management. Serves in an expanded health care role to collaborate with the patient’s primary care provider, specialists, other members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses, plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patient’s health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care. Understands and complies with PHSO standard work flows, upholding accreditation level standards.

Requirements

Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information.
Strong communication (verbal/written) and organizational skills, and ability to interact effectively with providers, clinic staff, and care management team members across the care continuum.
Highly proficient in use of computers and other technologies with the ability to troubleshoot and problem solve as needed.
Demonstrated capacity to problem solve and prioritize in complex situations.
Demonstrates a wide knowledge base and sound clinical skills to function as a nurse generalist.
Strong self-motivation and ability to work independently without direct supervision or support.
Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure.
Ability to function effectively in a team-based environment.
Basic Excel and Word skills.
Ability to understand and apply guidelines, policies, and procedures.
Obtain Certificate of Competency in Population Health Care Management within 12 months of hire.
Proof of completion of Mandatory Reporter within three months of hire.
Graduate from an accredited school of nursing.
Minimum of 5 years previous nursing experience or 3 years and BSN in lieu of experience.
Iowa state licensure as a Registered Nurse.

Nice To Haves

BSN preferred
Varied clinical experience preferred

Responsibilities

Performs patient identification and risk stratification following the ambulatory care management care model.
Maintains a panel of high-acuity patients engaged in Care Coordination Services.
Provides at least a monthly engagement conducted either by phone or virtually.
Completes routine assessments of physical, mental, social, and functional needs.
Develops, implements, and updates patient care plans.
Manages coordination and communication across providers, services, and markets.
Assesses for adherence, barriers, and gaps in recommended care.
Facilitates advance care planning discussions and the completion of advance directives for patients "≥" 18 years of age.
Manages transitions in care following hospital discharges, emergency department use, and post-acute stays.
Applies motivational interviewing to strengthen the patient’s own motivation for change and movement towards health behavior goals.
Provides coaching and education to support self-management.
Participates in quality improvement, measurement, and data collection to include populations with clinical and financial risk.
Accepts direct referrals from care management team members and providers.
Delegates to support team members as appropriate.
Informs primary care provider of ongoing care management activities, patient progress towards goals, and changes in the patient’s health status.
Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day.
Understands accountability for results and self-manages to support PHSO level success goals in the areas of quality, cost of care, and patient experience.
Upholds and supports PHSO standard workflows and procedures at accreditation level quality.