Overview

　　Works collaboratively with physicians, staff and other health care professionals within his/her clinically integrated network (CIN) to provide care management across the health care continuum for members within the CIN. Is 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. Coordinates a wide range of self-management support and disease registry activities for members and works with physicians and staff in various settings to address specific quality improvement/performance improvement initiatives. Collaborates with the CIN Population Health Care Management team on system-wide quality improvement/performance improvement initiatives.

　　Responsibilities

　　Works with “at risk” members and families on Self-Management Support including:

　　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 by:

　　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.

　　Optimizes member and family independence through teaching and the provision of available and necessary resources to access the health care delivery system across the continuum of care.

　　Performs 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 regarding specific health care skills and general disease concepts.

　　Assisting with shared medical appointments.

　　Communicating with members face-to-face in the office setting, by telephone, or by e-mail.

　　Effective collaboration, communication and coordination among all responsible parties of an individual member’s multidisciplinary health care team striving to eliminate fragmentation, duplication or gaps in treatment plans.

　　Works toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.

　　Maintains an active case load through use of “at risk” members using CHI’s identification and stratification tools, direct referrals from the member’s healthcare team (physician, Care Coordinator, hospital case manager, etc.) and other clinical knowledge.

　　Actively participates in Quality activities :

　　Assessing and collaborating with clinic managers and directors for CIN practices on strategies to achieve individual clinic level goals such as quality and efficiency.

　　Communicating and coordinating with the healthcare team in the development of tools for optimal patient outcomes and report findings.

　　Meets on a regular basis with other RN Population Health Coaches, as coordinated by CIN leadership, for information sharing and continuing education activities.

　　Accountability for results :

　　Understands and self-manages to support CIN-level success goals, including improvements in quality, cost of care and member experience for the CIN’s population.

　　Identifies opportunities for improvement (at individual, clinic and CIN levels) and actively works with healthcare and CIN team to correct or improve results.

　　Qualifications

　　Required Education for Staff Job Levels

　　Bachelor of Science in Nursing required; Masters of Science in Nursing preferred

　　Required Licensure and Certifications

　　Current unrestricted license by the State of Texas as a registered nurse

　　Required Minimum Knowledge, Skills and Abilities

　　Current unrestricted license by the State of Tennessee as a registered nurse

　　Bachelor of Science in Nursing required; Masters of Science in Nursing preferred

　　Five years of clinical and case management/health coach experience required.

　　Clinic/Physician office, home care, public health and/or social service experience preferred.

　　Experience in patient education preferred

　　Must have strong organizational (time management) skills, strong interpersonal skills and the ability to handle multiple priorities

　　Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word.

　　Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost) for individual users of health care and patient populations

　　Certification as Healthcare Coach or obtained within three years of hire.

　　Certification in case management (CCM), public health and/or community health preferred.

　　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.

　　Ability to work autonomously within matrix environment without direct supervision or support.

　　Demonstrates a wide theory base and sound clinical skills to function as a nurse generalist.

　　Pay Range

　　$29.02 - $42.08 /hour

　　We are an equal opportunity/affirmative action employer.