RN - Chronic Care / Health Coach

Ortonville Area Health Services; Ortonville (MN); On-site; USD 70,000 - 95,000; Full time

Job summary

Ortonville Area Health Services seeks an RN Chronic Care/Health Coach to provide comprehensive nursing care and care coordination for adults with chronic conditions. The role blends direct patient care with population health management, disease registry oversight, preventive services, and coaching to improve outcomes and meet quality goals.

The successful candidate will manage a panel of patients, develop individualized care plans, educate and coach patients, and follow up.

Qualifications

• Three years of professional nursing experience in a clinical setting preferred.
• Active RN license in Minnesota and South Dakota.
• Strong communication, patient education, and care coordination skills.
• Ability to work independently while collaborating with providers and clinic staff.
• Health Coach Certification within six months of hire.
• Maintain required continuing education and professional competencies.

Responsibilities

• Provide comprehensive nursing care and care coordination for patients with chronic/complex conditions.
• Combine direct patient care with population health management and chronic disease registry oversight.
• Deliver preventive care services and health coaching to improve outcomes and support quality initiatives.
• Develop a panel of patients for chronic care management and provide individualized care planning, education, coaching and follow-up.
• Maintain independent schedule of nurse visits and contribute to quality improvement through disease registry management and evidence-based interventions.

Skills

Communication

Patient education

Care coordination

Independent working

Education

RN license MN & SD

Job description

Description

The RN Chronic Care/Health Coash is responsible for providing comprehensive nursing care and care coordination services for patients with chronic and complex health conditions. This position combines direct patient care, population health management, chronic disease registry oversight, preventive care services, and health coaching to improve patient outcomes and support quality initiatives. The RN will develop a panel of patients requiring chronic care management and provide individualized care planning, education, coaching, and follow-up. The position will also maintain an independent schedule of nurse visits and contribute to organizational quality improvement efforts through disease registry management and implementation of evidence-based interventions.

Requirements

• Minimal of three years of professional nursing experience in a clinical setting preferred.
• Up to date Registered Nurse (RN) license in Minnesota and South Dakota.
• Strong communication, patient education, and care coordination skills.
• Ability to work independently while collaborating effectively with providers and clinic staff.
• Obtain Health Coach Certification within six (6) months of hire.
• Maintain required continuing education and professional competencies.

• This position is 76 hours per pay period.
• Per pay period you will have one full day off and one additional half day off.
• Hours are 7:30am - 5:00pm with 30m unpaid lunch