Registered Nurse - Transitional Care Population Health

ID_SARMC Saint Alphonsus Health System, Inc.; Baker City (OR); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Market-competitive pay

Generous PTO

Benefits from day one

Tuition reimbursement

Employee assistance programs

Job summary

Saint Alphonsus Health System's SAMG is seeking a Population Health RN to join the outpatient care team. The role focuses on coordinating transitions from acute to outpatient care, educating patients, and advocating for patient needs within the PCMH framework.

You will work with providers, clinic staff, and community partners to ensure seamless care delivery. Ideal candidates have an RN license, 5+ years in healthcare (ambulatory preferred), and experience with care/case management.

Qualifications

• Must have RN license as defined by primary work state.
• Minimum of five years of experience in healthcare setting, ambulatory preferred.
• License/Certification: associate or bachelor’s degree from an ACEN/CCNE-accredited nursing program.
• Basic Life Support for Healthcare Providers (BLS) certification required at hire.

Responsibilities

• Coordinate outpatient care (follow-up visits, home health, referrals, equipment).
• Educate patients and families on post-discharge care, meds, follow-ups, and screenings.
• Facilitate communication between patients, families and care teams.
• Advocate for patients to ensure timely outpatient care and appropriate resources.
• Identify and address barriers to outpatient care (transport, med access).
• Aim to improve health outcomes by reducing readmissions and managing chronic conditions.
• Contribute to key performance indicators by ensuring discharge instructions followed.

Skills

RN license

Case management

Communication

Education

AD or BSN in nursing

Tools

EPIC

Job description

Employment Type: Full time Shift: Day Shift Description: 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. Your responsibilities will encompass coordinating outpatient services, educating patients and families, facilitating communication within the healthcare team, and advocating for patient needs. You will identify and address barriers to successful outpatient care, implement strategies to improve health outcomes, and work towards achieving key healthcare metrics. Other responsibilities include supporting all Trinity Health initiatives to support quality outcome improvements. The Population Health RN supports the mission and goals of SAMG Patient Centered Medical Home (PCMH) through patient advocacy and patient centricity. Works 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.

General Requirements

• Must have an RN license, as defined by their 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.

Schedule: Mon - Fri (8 hr shifts).

ESSENTIAL FUNCTIONS

• 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 are essential 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.

Responsibilities

• Coordinate Outpatient Care: arrange and coordinate outpatient services such as but not limited to 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 as indicated on the patient’s after-visit summary, including medication management, follow-up appointments, and the importance of adherence, recommended preventative care screenings, community resources, and where to seek care in case of urgent or emergent symptoms.
• Facilitate Communication: acts 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, ensuring they receive appropriate and timely outpatient care and support.
• Identify Barriers: identify and address any barriers to successful outpatient care such as transportation issues or inability to obtain medications. Documentation of assessment using social influences of health in EPIC.
• Improve Health Outcomes: implement strategies to improve health outcomes, such as reducing readmission rates, managing hypertension, decreasing emergency department utilization, and increased communication with primary care provider.
• Impact Healthcare Metrics: work towards achieving key performance indicators by ensuring patients follow their discharge instructions, attend follow up appointments, and manager their conditions effectively.

HIGHLIGHTS AND BENEFITS

• When Saint Alphonsus takes care of you, you can take better care of our patients.
• We foster personal and professional growth and offer opportunities that empower our colleagues to develop their careers.
• Our belief in work-life balance compliments the natural beauty, diverse landscapes, and outdoor recreation lifestyle that is unique to Idaho and Oregon.
• 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 change as your needs develop.
• We are proud to offer Employee Assistance Programs, tuition reimbursement, and educational opportunities to help you learn and grow.

MINISTRY/FACILITY INFORMATION

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' goal is to improve the health and well-being of people by emphasizing care that is patient-centered, physician-led, innovative, and community-based. 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 through demonstrating an uncompromising commitment to improving patient survival and quality of life.

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.

Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.