Transitional Care RN - Population Health Program

Overview

Employment Type: Full time

Shift: Day Shift

Description:

Saint Alphonsus Health System is seeking people who are living out their calling, passionate about coming to work, and challenged to achieve potential. 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 coordinate outpatient services, educate patients and families, facilitate communication within the healthcare team, advocate for patient needs, identify barriers to successful outpatient care, implement strategies to improve health outcomes, and support quality outcome improvements aligned with Trinity Health initiatives.

The Population Health RN supports the mission and goals of SAMG Patient Centered Medical Home (PCMH) through patient advocacy and patient centricity. You will work collaboratively with provider care teams, clinic employees, other health care professionals, community services and stakeholders to provide a medical home for all patients within SAMG PCMH Primary Care.

• Coordinate Outpatient Care: arrange and coordinate outpatient services such as 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, including medication management, follow-up appointments, adherence, preventive care screenings, community resources, and where to seek care for urgent or emergent symptoms.

• Facilitate Communication: act 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 to ensure timely outpatient care and support.

• Identify Barriers: identify and address barriers to successful outpatient care (e.g., transportation, medication access); document assessment using social determinants of health in EPIC.

• Improve Health Outcomes: implement strategies to improve health outcomes (e.g., reduce readmissions, manage hypertension, decrease ED utilization, and improve communication with primary care providers).

• Impact Healthcare Metrics: work toward achieving key performance indicators by ensuring patients follow discharge instructions and attend follow-up appointments.

General Requirements:

• Must have an RN license, as defined by the 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. Case management and care management experience preferred.

License/Certification:

• 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 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.

• Coordinate Outpatient Care: arrange and coordinate outpatient services as described above.

• Educate Patients and Families: provide post-discharge education as indicated on the patient’s after-visit summary.

• Facilitate Communication: serve as a liaison to ensure continuity of care.

• Advocate for Patients: ensure timely outpatient care and appropriate support.

• Identify Barriers: assess and address barriers to outpatient care; document using EPIC.

• Improve Health Outcomes: implement strategies to reduce readmissions, manage chronic conditions, and enhance care…