Transitional Care RN - Population Health Program

Overview

At Saint Alphonsus Health System, we are looking for people who are living out their calling. We want you to be passionate about coming to work, and challenged to achieve your potential. Living by these virtues, we pride ourselves on exceptional service and the highest quality of care.

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 play a crucial role in ensuring smooth transitions for patients from acute care to outpatient care. You will identify and address barriers to successful outpatient care, implement strategies to improve health outcomes, and work towards achieving key healthcare metrics.

You will support all Trinity Health initiatives to support quality outcome improvements and support the mission and goals of SAMG Patient Centered Medical Home (PCMH) through patient advocacy and patient-centric care. You will work collaboratively with provider care teams, clinic employees, other health care professionals, community services and other 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, and adherence to recommended preventive care screenings and access to community resources.
• Facilitate communication: serve 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 such as transportation or medication access; document assessment using social determinants of health in EPIC.
• Improve health outcomes: implement strategies to reduce readmissions, manage hypertension, decrease ED utilization, and enhance communication with primary care.
• Impact healthcare metrics: work toward achieving key performance indicators by ensuring patients follow discharge instructions and attend follow-up appointments.

• 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.

• 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.

• We offer market-competitive pay, generous PTO, and multiple options for comprehensive benefits that begin on day one.
• Benefits for your future include retirement planning and matching, college savings plans for your family, and multiple life insurance plans that can adapt as needs develop.
• We are proud to offer Employee Assistance Programs, tuition reimbursement, and educational opportunities to help you learn and grow.

Saint Alphonsus Health System is a faith-based ministry and not-for-profit health system serving Idaho, Oregon, and northern Nevada communities. The health system boasts 4 hospitals, 609 licensed beds, and 73 clinic locations. Through innovative technologies, compassionate staff, and healing environments, Saint Alphonsus aims to improve the health and well-being of people by emphasizing patient-centered, physician-led, innovative, and community-based care.

• Top 15 Health Systems in the country by IBM Watson Health;
• The region’s most advanced Trauma Center (Level II);
• Commission on Cancer Accredited Program, demonstrating a commitment to improving patient survival and quality of life.

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.