Population Health RN Coach: Care Coordination

CHI; Nebraska City (NE); On-site; USD 51,000 - 74,000; Full time

Job summary

CHI Health St. Mary’s in Nebraska City is seeking a Population Health Coach to collaborate with physicians and staff to improve quality and sustainability.

You will manage chronic diseases, oversee referrals, interpret performance data, and implement Evidence-Based Metrics to ensure seamless transitions of care. The ideal candidate holds RN licensure in Nebraska with an Associate of Arts in Nursing and an advanced degree or 2 years of relevant experience; BSN and 3–5 years are preferred.

Qualifications

• Associate of Arts in Nursing required.
• Advanced degree or 2 years relevant experience required.
• Registered Nurse license for Nebraska required.

Responsibilities

• Care coordination via EMR with referrals to MSW, dietician, RxAP, and Certified Diabetic Educators.
• Receive referrals from providers/staff via EMR or in person settings.
• Refer patients to Prescription Assistance and Social Work programs as needed.
• Reach out to high-risk patients to close care gaps (wellness visits, screenings, etc.) and identify disease management opportunities.
• Educate about new diabetic medications and refer to Clinical Diabetes Education for ongoing follow-up.
• Respond to ED and inpatient discharge alerts with appropriate outreach as clinical judgment dictates.

Skills

Nursing

Collaboration

Data analysis

Education

AA in Nursing

BSN (preferred)

Job description

CHI Health St. Mary’s in Nebraska City is seeking a Population Health Coach to collaborate with physicians and staff to improve quality and sustainability.

You will manage chronic diseases, oversee referrals, interpret performance data, and implement Evidence-Based Metrics to ensure seamless transitions of care. The ideal candidate holds RN licensure in Nebraska with an Associate of Arts in Nursing and an advanced degree or 2 years of relevant experience; BSN and 3–5 years are preferred.