Job Description
Pro-actively consults with the interdisciplinary team which includes but is not limited to hospital patient care staff, Physicians, Pender Medical Clinic staff, patient support and family and community resources to assure a smooth transition for the patient through appropriate levels of care in order to facilitate quality outcomes. Provides professional RN health coaching for patient self-management in accordance with the philosophy, goals and objectives of Pender Community Hospital.
Utilizes population health strategies to address chronic care needs or risk factor reduction for all patients who may benefit from health coaching and care coordination.
Performs coordination of care across the care continuum.
Works with patients and families on Self-Management Support which includes setting short and long term goals, medication adherence, provides or arranges patient education and making follow up plans.
Conducts pre-visit chart review for all wellness and chronic care visits.
Provides education and advocates disease prevention along with link to community resources.
Identifies patients not meeting clinical goals, such as BP control or glucose control and arranges for follow up services by protocol or as appropriate.
Stays involved with QI activities and coordinate program components with Business Office Lead , CEO and ACO manager.
Reviews patient medical records to identify patients overdue for visits, labs and referrals, and arranges for follow up services as needed.
Communicates and coordinates with all the healthcare team to assist patient achieve optimal outcomes.
Reports findings of patient outcomes to staff and providers in a timely manner. Provides requested reports on preventative services as needed.
Educates staff on the importance of preventative examinations and wellness for themselves and their family.
Performs other duties as assigned.
Hours: Minimum 40 hours/week, Monday-Friday, 8:00am-5:00pm
Education, Experience:
Associates Degree, Bachelor's of Science in Nursing preferred
Equivalent of at least two (2) years nursing experience
Must have knowledge of specific disease and lifestyle related topics
Previous experience in health and wellness preferred
Effective knowledge and familiarity with word processing, computer navigation, and e-mail
Certificates, Licensure, Registrations:
Currently licensed as a Registered Nurse in the State of Nebraska or multi state licensure in a nurse licensure compact state
Valid Nebraska driver's license
Basic Life Support (BLS)
CWC Certified Wellness Coach or Health Coach Training preferred
GENERAL REQUIREMENTS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Ability to add, subtract, multiple and divide
Ability to read, interpret, and take action as it relates to basic documentation and information
Ability to write reports and correspondence
Ability to use computer software, computer navigation, and internet
Ability to effectively present information to patients, families, employees, and health care providers
Ability to work cooperatively and communicate effectively to maintain good working relationships with staff and health care providers
Ability to work with skill in identify problems
EQUIPMENT, TOOLS, MATERIALS
Knowledge of computer hardware equipment and software applications relevant to work functions.
Standard full-time benefits: Benefits go into effect the 1st of the month following 30 days of hire. Include but not limited to:
This institution is an EEO/AA Employer and Provider - Protected Veterans and Individuals with Disabilities.
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