Registered Nurse - Transitional Care Population Health

Trinity Health•Baker City, OR

About The Position

Saint Alphonsus Medical Group is seeking a Population Health RN to support its Patient Centered Medical Home primary care teams. The nurse helps patients transition from acute care to outpatient care by coordinating services, educating patients and families, facilitating communication among patients and the healthcare team, and advocating for patient needs. The role identifies barriers to successful outpatient care, implements strategies to improve health outcomes, and supports Trinity Health quality improvement initiatives and key healthcare metrics. The Population Health RN works collaboratively with provider care teams, clinic employees, other healthcare professionals, community services, and stakeholders to provide a medical home for patients. The position is scheduled Monday through Friday in eight-hour day shifts.

Requirements

An RN license issued by the nurse’s primary work state, Idaho, before the hire date.
Provide licensure or proof of application for the secondary state, Oregon, within six months of hire.
At least five years of experience in a healthcare setting.
An associate or bachelor’s degree from a nursing program accredited by ACEN or CCNE.
Basic Life Support for Healthcare Providers certification from AHA, ARC, or the Military Training Network at hire.
Knowledge of evidence-based behavioral change methodologies and motivational coaching techniques.
Excellent interpersonal, communication, and documentation skills, with the ability to relate to and motivate a diverse group of patients and clinical staff.
Knowledge of and experience using EPIC to assess patient status and communicate within the care team in inpatient and outpatient settings.

Nice To Haves

Ambulatory healthcare experience.
Case management and care management experience.
Knowledge of performance improvement, billing, coding, and documentation requirements.

Responsibilities

Coordinate outpatient services, including follow-up visits with primary care providers and specialists, home health care, referrals to community resources, long-term care managers, and durable medical equipment.
Educate patients and families about post-discharge care, medication management, follow-up appointments, adherence, recommended preventive screenings, community resources, and where to seek care for urgent or emergent symptoms.
Facilitate communication between patients, families, and the healthcare team to support clear communication and continuity of care.
Advocate for patients’ needs and preferences to help ensure they receive appropriate and timely outpatient care and support.
Identify and address barriers to outpatient care, such as transportation issues or inability to obtain medications, and document assessments using social influences of health in EPIC.
Implement strategies to improve health outcomes, including reducing readmissions, managing hypertension, decreasing emergency department utilization, and increasing communication with primary care providers.
Work toward key performance indicators by supporting patients to follow discharge instructions, attend follow-up appointments, and manage their conditions effectively.
Support Trinity Health initiatives and quality outcome improvements.