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RN-Population Health Coach

Company: Catholic Health Initiative
Location: Bryan
Posted on: June 12, 2021

Job Description:


CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S., from clinics and hospitals to home-based care and virtual care services, CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources, CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community.



Provide care management across the health care continuum for members within the CIN and ACO. Serve as an integral member of the health care team as well as the CIN department team who works to ensure safety, best practice and high quality standards of care are maintained. Coordinate a wide range of self-management support and disease registry activities for members. Navigate patients through the healthcare delivery system (inpatient, outpatient, ambulatory settings) for patients actively needing/ seeking care and will also engage patients who have been identified as needing interventions but not yet actively seeking assistance from their provider. Work with physicians, group practices, PODs and clinical inpatient and outpatient and staff in various settings to address specific quality improvement/performance improvement initiatives. Collaborates with the CIN Population Health Coach team on system-wide quality improvement/performance improvement initiatives.POSITION RESPONSIBILITIES

  1. Work with "at risk" members and families on Self-Management Support, such as, but not limited to: setting short and long-term goals for self-management of chronic disease; addressing medication adherence in patients not meeting outcome goals, working with members to create a plan for health behavior change; performing individual needs assessment, care plan design, documentation and implementation, and evaluation of outcomes; communicating a plan for healthcare needs between physician/office visits; providing needed patient education; and reducing of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.2. Engage patients at the point of care (Inpatient and clinic settings) and establish a relationship/case plan that continues outside of the point of care with the primary goal of improving patient health as the patient and their physician define health.3. Set clear expectations for patient responsibilities, support patient self-management in recovery, and establish feedback loops between patients and providers to identify complications early on.4. Proactively identify solutions to promote low acuity utilization before complications become high priority.5. Leverage data to identify changes in the health status of well-managed patients.6. Identify and implement case plans that are patient centric. Communicate with patients using the patients preferred method of communication.7. Follow evidence-based care pathways, coordinating care across multiple provider sites, and ensure patients follow recommended recovery care plans.8. Collaborate with CHI TX Division providers and staff within their offices/clinics. Focus on cultivating collaborative working relationships with all community providers who interact with our patients with the goal of providing patient centric care.9. Collaborate with healthcare providers in the community not affiliated with CHI TX Division. Focus on cultivating collaborative working relationships with all community providers who interact with our patients with the goal of providing patient centric care.10. Actively Participates in Quality activities, such as, but not limited to: strategies to achieve individual clinic level quality and efficiency goals, and working with healthcare team in the development of tools for optimal patient outcomes and report findings. Participate in workflow committees to develop best practices.11. Identifies opportunities for improvement (at individual, clinic and CIN levels) and actively Works with healthcare and CIN team to correct or improve results.12. Maintains latest skills and knowledge related to the job.13. Performs other duties as assigned to meet the organization`s needs.


Education and Licensure Required:

  • Associate's Degree preferredRegistered Nurse (RN)Healthcare Coach Certification or Certified Care Manager (CCM); or obtained within three (3) years of hireBasic Life Support (BLS) for the Healthcare Provider certified or obtained by the end of the orientation period (approximately six (6) weeks)Proof of completion of Mandatory Reporter abuse training specific to population served within three (3) months of hire

Minimum Experience:*Five (5) years of clinical and case management/health coach experience required, (Care Management, Utilization Management, ER, ICU also acceptable)

Minimum Knowledge, Skills, and Abilities:Must have strong organizational (time management) and interpersonal skillsAbility to handle multiple prioritiesMust possess strong customer service skills to coordinate services. Must have effective communication, telephonic skills.Computer skills to include navigating complex reporting software and Microsoft Office.*Ability to articulate care plan and patient needs to providers. Ability to identify patient self-directed care plans

Keywords: Catholic Health Initiative, Bryan , RN-Population Health Coach, Other , Bryan, Texas

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