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Employment Type:

Full time

Shift:

Description:

ESSENTIAL KEY JOB RESPONSIBILITIES

1. Works with patients and families on Self –Management Support including:

a. Setting short- and long-term goals for self-management of chronic disease.

b. Addressing medication adherence in patients not meeting outcome goals.

c. Working with patient to create a plan for Health Behavior Change utilizing the 5 A’s approach:

i. Assessing and working on the patient’s readiness to change, the importance of change, and confidence in ability to change.

ii. Helping the patient to identify and overcome barriers

iii. Optimizing member and family independence through coordinating and ensuring the provision of available and necessary resource to access the health care delivery system across the continuum of care.

iv. Making a plan for follow up between visits

d. Performs individual needs assessment, care plan design, documentation and implementation and evaluation of outcomes.

e. Communicates a plan for healthcare needs between physician/office visits.

f. Coordinates needed patient education regarding specific health care skills and general disease concepts.

g. Effective collaboration, communication and coordination among all responsible parties of an in individual members’ multidisciplinary health care team, striving to eliminate fragmentation, duplication or gaps in treatment plans.

h. Works toward reduction of preventable hospital admission, re-admissions, excessive therapies, DME and other potentially preventable services.

i. Communicates face to face in the office setting, by telephone or by email.

j. Assesses patient’s beliefs, wishes and values regarding advance directives and works with the care team to document and implement such wishes.

k. Assess patient’s understanding of personal exacerbation triggers. Provides or coordinates educational need regarding the identification of triggers and actions to take when triggers are noted.

2. Provides coordination of care across the care continuum. Assists in identifying at risk or high risk member populations, assists as liaison with patient/families and their physicians or others, acts a liaison with hospitalized patients and clinic, promotes coordination with all care providers, acts as patient advocate and identify barriers to patient’s ability to self-manage.

3. Actively participates in QI activities, assessing and collaborating with clinic manager on strategies to achieve individual clinic goals such as quality and efficiency.

4. Provides oversight of the disease registry database to insure it is up to date, identify the overdue for visits, those not meeting clinical goals and creating patient, physician and clinic level quality performance reports.

5. Provides oversight or conducts pre-visit chart review of patients including identification of all preventative health maintenance, immunizations and chronic disease interventions.

6. Accountable for patient results. Understands and self-manages to support success goals, identifies opportunities for improvement, maintains and active caseload of high-risk members, follows standardized care management protocols and documents all care management activities.

MINIMUM QUALIFICATIONS

Required Education (for CHI Leadership Job Levels from Supervisor through President) Does Not Apply

Required Education for Staff Job Levels Completion of accredited RN program, 2- or 4-year program.

Required Licensure and Certifications Current Iowa licensed RN Certification as Healthcare Coach or obtained within one year of hire BLS for Healthcare Provider Mandatory Reporter abuse training certified or within 6 months of hire.

Required Minimum Knowledge, Skills and Abilities Competent computer skills, good use of English language,

PREFERRED Qualifications Certification in case management (CCM), public health and or community health.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is 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, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran