Population Health Coach RN
About The Position
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.
Requirements
- Associate Of Arts in Nursing
- Advanced degree or 2 years relevant experience, upon hire
- Registered Nurse: NE, upon hire
Nice To Haves
- Bachelors Of Science of Nursing
- 3 to 5 years experience, upon hire
Responsibilities
- Manage chronic diseases through education.
- Oversee referral patterns based on quality and patient experience.
- Interpret performance data to develop workflows.
- Implement Evidence-Based Metric (EBM) guidelines, ensuring seamless transitions of care across settings.
- Identify and coordinate referrals to team members via EMR, i.e. 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 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.
- Education on new injectable medication and referral to Clinical Diabetes Education (CDE) for formal DM education and continued follow up.
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
