Transitional Care RN - Population Health Program – Full Time Days

Trinity Health • Boise, ID

1d

About The Position

At Saint Alphonsus Health System, we are looking for people who are living out their calling. We want you to be passionate about coming to work, and challenged to achieve your potential. Living by these virtues, we pride ourselves on exceptional service and the highest quality of care. Saint Alphonsus Medical Group (SAMG) is seeking a Population Health RN to join their growing team! As an Outpatient RN, Population Health Nurse, you will play a crucial role in ensuring smooth transitions for patients from acute care to outpatient care. Your responsibilities will encompass coordinating outpatient services, educating patients and families, facilitating communication within the healthcare team, and advocating for patient needs. You will identify and address barriers to successful outpatient care, implement strategies to improve health outcomes, and work towards achieving key healthcare metrics. Other responsibilities include supporting all Trinity Health initiatives to support quality outcome improvements. The Population Health RN supports the mission and goals of SAMG Patient Centered Medical Home (PCMH) through patient advocacy and patient centricity. Works collaboratively with provider care teams, clinic employees, other health care professionals, community services and other stakeholders to provide a medical home for all patients within SAMG PCMH Primary Care.

Requirements

• Must have an RN license, as defined by their primary work state (Idaho) issued prior to hire date.
• Must provide licensure or proof of application in secondary state (Oregon) within six months of hire.
• Minimum of five years of experience in healthcare setting required, preferably ambulatory.
• An associate or bachelor's degree from a nursing program accredited by ACEN or CCNE
• Basic Life Support for Healthcare providers certification from either AHA, ARC or the Military Training Network is required at hire.
• Knowledge of performance improvement, billing, coding, and documentation requirements highly desired
• Knowledge of evidence-based behavioral change methodologies and motivational coaching techniques.
• Excellent interpersonal, communication and documentation skills are essential with the ability to relate and motivate effectively with a diverse group of patients and clinical staff.
• Knowledge of and experience in the use of EPIC, the electronic health record, to assess patient status and communication within the care team, both inpatient and outpatient.

Nice To Haves

• Case management and care management experience preferred.

Responsibilities

• Coordinate Outpatient Care: arrange and coordinate outpatient services such as but not limited to 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: provide detailed education on post-discharge care as indicated on the patient’s after-visit summary, including medication management, follow-up appointments, and the importance of adherence, recommended preventative care screenings, community resources, and where to seek care in case of urgent or emergent symptoms.
• Facilitate Communication: acts as a point of contact between patients, families, and the healthcare team to ensure clear communication and continuity of care.
• Advocate for Patients: advocate for patients’ needs and preferences, ensuring they receive appropriate and timely outpatient care and support.
• Identify Barriers: identify and address any barriers to successful outpatient care such as transportation issues or inability to obtain medications. Documentation of assessment using social influences of health in EPIC.
• Improve Health Outcomes: implement strategies to improve health outcomes, such as reducing readmission rates, managing hypertension, decreasing emergency department utilization, and increased communication with primary care provider.
• Impact Healthcare Metrics: work towards achieving key performance indicators by ensuring patients follow their discharge instructions, attend follow up appointments, and manager their conditions effectively.

Benefits

• We offer market-competitive pay, generous PTO, and multiple options for comprehensive benefits that begin on day one.
• Benefits for your future include retirement planning and matching, college savings plans for your family, and multiple life insurance plans that can change as your needs develop.
• We are proud to offer Employee Assistance Programs, tuition reimbursement, and educational opportunities to help you learn and grow.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees