Job Summary Schedule: Monday- Friday, 8:00am-4:0pm Remote The RN Coach will function in a telephonic virtual care center and is part of the Care Connections Team which collaborates with physicians, mid-level providers, staff, and other health care professionals to provide coordination of care across the health care continuum. The RN Coach will also focus on enhancing the patient experience by recommending primary and specialty care providers as well as community resources. This role serves as an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum. Responsibilities include, but are not limited to assisting, developing and coordinating a wide range of self-management support, chronic-care management as well as acute triage. Position responsibilities are met through providing information pertaining to acute healthcare needs while promoting health and well-being. The RN Coach also supports holistic interdisciplinary patient centered care. The RN Coach also supports holistic interdisciplinary patient centered care as part of the Care Connections team. Care Connections promotes the effective self-management of chronic-care and assists patients with navigating the healthcare system. In addition, this role may include answering a nurse triage line responsible for assessing problems over the phone utilizing appropriate and approved protocols. Some functions may include, but are not limited to: responding to general health questions, assessing appropriate healthcare access for the patient by utilizing approved protocols and encourages promoting patient engagement to reduce the risk of hospitalization. While this role will be responsible for telephone triage to assess a patients’ needs and provide relevant health information the RN will not make medical diagnoses or tell the caller what may be wrong. Responsibilities + Care Connections Management and Chronic-Care Management Activities: Aids with defining a disease-specific patient database (registry) in coordination with clinic management and medical director. Assists to create and test processes to identify patients appropriate for chronic-care management services (i.e. overdue for visits, labs, referrals, meeting identified clinical goals such as blood pressure control or glucose control). Works with Population Health to develop and refine systems necessary to manage patient referrals from providers and staff to appropriate self-management education and support. This includes answering the nurse call line as assigned and helping to navigate and/or coordinate the patient’s care which may include general health advice and/or guide to the appropriate level of care by utilizing identified protocols. + Pre-Visit Chart Reviews: Identification of needed preventive health maintenance, immunizations, and chronic disease interventions. Assists to create and sustain protocols which allow initial and/or follow-up services to be ordered or completed before the patient sees the provider, in order to enhance patient experiences. This position assists Population Health with determining particular patient needs. Works with Novant Health resources to identify opportunities to enhance processes to improve patient flow and enhance patient experiences and medical care across the system. + Self-Management Support: Assists with Population Health programs and defined tools to aid in the identification of risks, symptoms and opportunities to improve; directing patients to appropriate levels of care. Assists patients to create a plan for Health Behavior Change using the Behavior Change Model – Assessing their stage as one of the following: Pre-contemplation Stage, Contemplation Stage, Preparation Stage, Action Stage, or Maintenance and Relapse Prevention Stage - with the understanding that most people ‘recycle’ through the stages several times before true change is established. Assists to create a plan with the patient / caregiver for follow-up between provider visits, as appropriate. Assists to provide program-defined written health education materials and tools to provide to chronic-care patients in an effort to begin to minimize the impact of their conditions. Qualifications + Education: Graduate of an accredited school of nursing, required. BSN, preferred. 4 Year / Bachelors Degree. preferred. + Experience: Minimum of five years clinical experience in hospital, home health, or community setting with a recent focus on acute and/or chronic-care management, required. Case management experience, preferred. + Licensure/Certification: Current RN license for all states in NH footprint, required. + Additional Skills (required): Broad clinical knowledge base of multiple conditions and expected outcomes. Working knowledge of effective teaching techniques, applying adult learning principles. Ability to demonstrate coordination of appropriate educational materials for patients and their support systems. Demonstrates appropriate professional nursing skills in the provision of preventive health maintenance and/or treatment of illness. Demonstrate appropriate clinical leadership skills as evidenced by previous work related activities and performances. Demonstrate the ability to work independently to assess and evaluate understanding of disease processes, treatment plans and/or lifestyle changes. Demonstrate sound knowledge and appropriate decision-making skills for designated patient populations. Demonstrate appropriate organization skill Demonstrate the ability to assess self-learning needs and seek ways to meet own professional development by proactively educating self, participating in orientation and staff development activities, maintaining knowledge of clinical practice, issues, trends, technology and available community resources, and uses policies and procedures appropriately. Possesses excellent computer skills with the ability to multitask including navigating and documenting in an EMR while communicating with the patient. In addition this person will have strong problem solving and analytical skills and demonstrate communication, organizational, and interpersonal skills. Has a broad clinical knowledge base of multiple conditions and expected outcomes as well as working knowledge of effective teaching techniques, applying adult learning principles. Job Opening ID 114821