Population Health Coach RN

Job Summary and Responsibilities As ourPopulation Health Coach RN, you will play a pivotal role in maintaining and improving the quality and sustainability of our clinically integrated network (CIN). By leveraging evidence-based metric (EBM) guidelines and data-driven workflows, you will bridge the gap between clinic, post-acute, and inpatient settings. You will serve as a vital clinical partner to physicians and staff, ensuring that our patient population receives high-quality, seamless, and patient-centered care while optimizing value-based performance outcomes. Every day you will facilitate comprehensive care coordination by managing clinical referrals, monitoring high-risk patient populations, and closing critical care gaps such as annual wellness visits and preventative screenings. You will utilize the Innovaccer platform to conduct timely outreach for patients discharged from ED or inpatient units, provide education on new diabetic medications, and connect vulnerable patients with essential financial and prescription assistance programs. Your daily focus will remain on fostering collaboration across the healthcare continuum—including social work, dieticians, and home health teams—to guarantee smooth transitions and improved health outcomes. To be successful in this role, you will need to possess strong organizational and time-management skills, allowing you to work autonomously in a complex matrix environment. You must demonstrate proficiency in EMR systems and Microsoft Office, along with a deep understanding of information technology used to evaluate care effectiveness. Your ability to communicate effectively with interdisciplinary teams, handle multiple clinical priorities with precision, and adapt to evolving program goals will be essential to your success in this dynamic population health role. Care Management & Outreach: Proactively manage high-risk patients and those with chronic diseases by closing clinical care gaps (such as annual wellness visits, colonoscopies, and mammograms) and facilitating necessary preventative health interventions. Seamless Care Transitions: Serve as a clinical bridge between acute, post-acute, and ambulatory care settings. This includes receiving and acting on ED/Inpatient discharge alerts to ensure smooth transitions and appropriate follow-up care for patients returning home. Interdisciplinary Care Coordination: Function as a central point of contact for the clinical team by coordinating referrals for social work, dieticians, prescription assistance, and diabetes education to ensure a holistic approach to patient health. Evidence-Based Practice Implementation: Apply and hardwire clinical evidence-based metric (EBM) guidelines within the clinic setting to improve overall quality of care and patient experience outcomes. Clinical Performance Tracking: Utilize information technology and data platforms (such as Innovaccer) to monitor workflows, track patient status, and report on care effectiveness to support the quality and sustainability of the clinically integrated network. We are offering up to $5,000 as a Sign-on Bonus as well as up to $10,000 in Educational Assistance to new hires who meet the eligibility requirements. Job Requirements Education Associate Degree in Nursing (Required) Bachelor’s Degree in Nursing (Preferred). Experience Minimum of 2 years of nursing experience required 3–5 years preferred. Licensure Current Nebraska (NE) Registered Nurse license required (Compact accepted). Where You’ll Work CHI Health Schuyler opened its doors on October 11, 1953, serving the communities of Schuyler, Clarkson, Howells, Leigh and the residents of rural Colfax County in Nebraska. In addition to its 25 critical access beds, CHI Health Schuyler offers a wide variety of services to residents–children, teens, adults, senior citizens, friends and neighbors. CHI Health Schuyler is proud to provide health care services close to home. #J-18808-Ljbffr CommonSpirit Health