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RN-Population Health Coach (Sepsis) - Clinically Integrated Network

Company: Mercy Medical Center
Location: Des Moines
Posted on: September 22, 2019

Job Description:

Position Type: Regular Scheduled Hours per 2 week Pay Period: 80 Primary Location: IA > DES MOINES > MERCY MEDICAL CENTER GENERAL SUMMARY: Works collaboratively with physicians, staff and other health care professionals within his/her individual clinic to provide a medical home and care coordination across the health care continuum for patients within the physician office setting. Is an integral member of the clinic health care team as well as the ACO department team who works to ensure safety, best practice and high quality standards of care are maintained. Coordinates a wide range of self-management support and disease registry activities for medical home patients. Collaborates with physicians and staff in clinic specific quality improvement/performance improvement initiatives. Partners with the Health Coach Assistant and other members of the team on system wide quality improvement/performance improvement initiatives. ESSENTIAL FUNCTIONS: • Provide oversight of the disease registry database including: a) Assuring database is kept up to date. b) Identifying patients overdue for visits, labs, or referrals and arranging for follow-up services as appropriate. c) Identifying patients not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate. d) Creating patient, physician, and clinic level quality performance reports. • May provide oversight or conduct pre-visit chart review of patients including: a) Identifying needed preventive health maintenance, immunizations, and chronic disease interventions. b) Effectively communicates the review to the provider and other key staff as appropriate. c) Reviews identified insurance care gaps and works to improve the clinical outcomes • Works with patients and families on Self-Management Support including: a) Setting short and long-term goals for self-management of chronic disease. b) Addressing medication adherence in patients not meeting outcome goals. c) Working with patient to create a plan for health behavior change utilizing the 5A’s approach ? - Assessing and working on the patient’s readiness to change, the importance of change, and confidence in ability to change. ? - Helping the patient to identify and overcome barriers d) Making a plan for follow-up between visits e) Providing needed patient education regarding specific health care skills and general disease concepts. f) Assisting with shared medical appointments. g) Communicating face-to-face in the office setting, by telephone, mail or by e-mail. • Provides Coordination of Care across the care continuum including: a) Assisting as liaison with patients and their families to physicians, clinical staff, and other departments. b) Acting as a liaison with hospitalized patients and the clinic, following up with patients by phone shortly after hospital discharge. c) Acting as a liaison with specialty clinics. d) Proactively acting as patient advocate, responding to and working to resolve patient concerns e) Providing a link to community resources • Actively participates in QI activities: a) Assessing and collaborating with Clinic Managers and Providers on strategies to achieve individual clinic level goals such as quality and efficiency. b) Actively participating/coordinating committees as needed/requested by the Clinic Manager or Clinic Director, i.e. Performance Improvement Teams. c) Communicating and coordinating with the healthcare team in the development of tools for optimal patient outcomes and report findings. d) Meets on a regular basis with other Health Coach, team members as coordinated by the Health Coach Managers for information sharing and continuing education activities. MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED: • Possession of a current of compact state license as a registered nurse issued/defined by the State of Iowa. • Clinic/Physician office experience preferred. • 1-2 years of acute care or home care experience preferred • Experience in patient education preferred. • Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills. • Certification as Healthcare Coach or obtained within one year of hire. • Basic 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. Additional Information Requisition ID: 2019-R0245954 Schedule: Full-time Market: Mercy Medical Center

Keywords: Mercy Medical Center, Ames , RN-Population Health Coach (Sepsis) - Clinically Integrated Network, Other , Des Moines, Iowa

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