Employment Type:

Shift:

Description:

Remote Position - Must live in Iowa

Job Summary: The RN Ambulatory Health Coach provides care management and care coordination services to Population Health patients with complex illnesses residing in the community setting. This includes managing a panel of high-acuity patients, managing their transitions in care across the care continuum, and providing coaching and education to support patient self-management. Serves in an expanded health care role to collaborate with the patient’s primary care provider, specialists, other members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses, plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patient’s health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols in the development of individualized care plans that are patient-centric,

promoting quality and efficiency in the delivery of health care. Understands and complies with PHSO standard work flows, upholding accreditation level standards.

Essential Position Expectations:

1. Performs patient identification and risk stratification following the ambulatory care management care model.

2. Maintains a panel of high-acuity patients engaged in Care Coordination Services:

§ Provides at least a monthly engagement conducted either by phone or virtually

§ Completes routine assessments of physical, mental, social, and functional needs

§ Develops, implements, and updates patient care plans

§ Manages coordination and communication across providers, services, and markets

§ Assess for adherence, barriers, and gaps in recommended care

§ Facilitates advance care planning discussions and the completion of advance directives for patients ≥ 18 years of age

§ Manages transitions in care following hospital discharges, emergency department use, and post-acute stays

3. Applies motivational interviewing to strengthen the patient’s own motivation for change and movement towards health behavior goals.

4. Provides coaching and education to support self-management.

5. Participates in quality improvement, measurement, and data collection to include populations with clinical and financial risk.

6. Accepts direct referrals from care management team members and providers.

7. Delegates to support team members as appropriate.

8. Informs primary care provider of ongoing care management activities, patient progress towards goals, and changes in the patient’s health status.

9. Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day.

10. Understands accountability for results and self-manages to support PHSO level success goals in the areas of quality, cost of care, and patient experience.

11. Upholds and supports PHSO standard workflows and procedures at accreditation level quality.

Knowledge & Skills:

1. Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information.

2. Strong communication (verbal/written) and organizational skills, and ability to interact effectively with providers, clinic staff, and care management team members across the care continuum.

3. Highly proficient in use of computers and other technologies with the ability to troubleshoot and problem solve as needed.

4. Demonstrated capacity to problem solve and prioritize in complex situations.

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

6. Strong self-motivation and ability to work independently without direct supervision or support.

7. Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure.

8. Ability to function effectively in a team-based environment.

9. Basic Excel and Word skills.

10. Ability to understand and apply guidelines, policies, and procedures.

11. Obtain Certificate of Competency in Population Health Care Management within 12 months of hire.

12. Proof of completion of Mandatory Reporter within three months of hire.

Mental & Physical Demands:

1. Must be able to pass a pre-employment drug screening test at time of hire.

2. Work with regular and predictable attendance.

3. Maneuver within the physical work environment with some bending, stooping, reaching, and light lifting.

4. Constantly able to use hands and fingers to type, write, and file. Frequently able to use near vision for viewing computer monitors and written materials. Occasionally required to detect unusual odors that could indicate environmental issues.

5. Use of usual and customary equipment used to perform essential functions of the position.

Education: Graduate from an accredited school of nursing. BSN preferred.

Experience: Minimum of 5 years previous nursing experience or 3 years and BSN in lieu of experience. Varied clinical experience preferred.

Certifications & Licenses: Iowa state licensure as a Registered Nurse.

The above is intended to describe the general content of and requirements for this job. It is not intended to be a complete statement of duties, responsibilities or requirements.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.