RN Chronic Care & Health Coach — Independent Schedule

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

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.