Registered Nurse Health Coach

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Works collaboratively with heath care professionals including physicians, nurses, therapies and support staff to provide a medical home and care coordination across the health care continuum. Care is focused on those patients identified as patients requiring the medical home service within the physician clinic office setting. Works as an integral member of the health care team to ensure safety, best practice, and high quality standards of care are maintained across the continuum. Responsible for coordinating a wide range of self-management support and disease registry activities for the clinic's entire patient population.

Reports to
As Assigned

Education, Experience and Skills Requirements
Must have graduated from an accredited school or college of nursing. Bachelor's degree in nursing is required. If incumbent does not possess a Bachelor's Degree in Nursing, must be in process of obtaining or able to obtain within three years. Specific services/positions may have additional education, training or experience requirements. Minimum of 5 years of RN experience required, with at least 2 years in ambulatory care preferred. Must have a thorough knowledge of nursing principles, practices, and techniques, including the American Association of Ambulatory Care Nursing Standards of Practice. Must also be able to implement appropriate administrative and management principles. Board certification in ambulatory care nursing preferred.

Licensure/Certification Requirement
Must be licensed as a Registered Nurse in the state/states of practice. Nurses performing nursing practice over the telephone require licensure in the states where the patients being served reside.

Job Specific Competencies
  • Utilizes current concepts and practice management principles of the Medical Home program.
  • Proactively assists/supports the physician and other providers in managing /delivering coordinated acute, chronic, preventive, and end-of-life care for patients via face-to-face and telephone interaction.
  • Participates in coordination of care across the continuum by acting as a liaison between patients, families, and members of the health care team.
  • Provides a link to community resources and assists with arrangement of appropriate referrals.
  • Conducts pre-visit chart review of patients and utilizes technology to organize patient information prior to patient visits.
  • Educates patients and families on self-management techniques and disease specific information.
  • Advocates disease prevention, health, and promotion of healthy lifestyles.
  • Utilizes motivational interviewing principles to promote patient behavior change and support patients to develop action plans to meet goals.
  • Assists patients to develop and utilize problem solving skills.
  • Integrates and leverages technology tools within the clinical practice to identify, track, and evaluate the success of chronic disease prevention and management interventions.
  • Examines data to identify what tests/exams need to be done to meet standards of care.
  • Understands Quality Improvement measures and how to impact results.
  • Assists in completion of risk stratification tool.
  • Identifies patients not meeting clinical goals and arranges follow-up services by protocol or as appropriate.
  • Monitors, evaluates and notates trends in patient responses and identifies risk issues, variances and improvement opportunities.
  • Participates effectively as a team member in the clinic setting, being accountable, helpful, and welcoming to coworkers, providers, and patients.
  • Proactively acts as a patients advocate, responding with empathy and respect to resolve patient concerns and recognizes opportunities for improvement through patient concerns.
  • Identifies patients not meeting clinical goals and arranges follow-up services by protocol or as appropriate.
  • Maintains efficient, cost effective care.

Core Competencies
Customer Service
  • Interacts with customers in a warm and friendly way.
  • Takes immediate action to meet customer requests or needs.
  • Listens to understand what customers have to say.
  • Recognizes safety hazards and takes corrective action; seeking assistance when needed.
  • Demonstrates knowledge of operational policies and procedures.
  • Performs work safely, without causing harm or risk to self, others or property.
System Behavior
  • Makes a decision considering the impact of the decision on other areas.
  • Initiates collaboration with others outside of service area.
  • Demonstrates personal commitment to the principles, values, and ethics of the organization.
  • Models accountability for learning by sharing knowledge and learning from others.
  • Builds effective working relationships.
  • Expresses appreciation to others for their work.
  • Treats others with respect.

Leadership Competencies
  • Defines and delegates work responsibilities with clear, consistent expectations and outcomes.
  • Demonstrates both knowledge and application of Sanford policies, procedures, and guidelines.
  • Demonstrates the ability to take charge, take unpopular stands if necessary, face difficult situations, and is looked to for direction from others.
  • Facilitates and supports change within the Sanford Health.
  • Demonstrates commitment to continuous learning for themselves and staff.
  • Demonstrates and applies continuous quality improvement knowledge and skills.

Information Management Competencies
  • Demonstrates skill in accessing, preparing and using information as relevant to position.
  • Verbalizes and demonstrates knowledge of procedures for maintaining security, confidentiality and integrity of employee, patient, family and other medical information.
  • Demonstrates ability to collect, analyze and present data as appropriate to position.

Equipment Competencies
  • Demonstrates skill in use of equipment relevant to position; verbalizes knowledge of appropriate safety procedures.
  • Diagnoses equipment problems; fixes or seeks out someone to fix.
  • Consistently informs appropriate person of problems encountered with repairs or calibration of equipment.

Professional/Clinical Practice Competencies
  • Assessment: Conducts and documents nursing assessments of health status by collecting objective and subjective data from observations, exams, interviews and written records; sorting, selecting, reporting and recording the data; validating, refining, and modifying the data. Bases the scope and depth of assessment on the patients immediate condition or need.
  • Diagnosis: Analyzes the assessment data to establish or modify nursing diagnoses to be used as a basis for nursing interventions.
  • Planning: In collaboration with the patient, develops a plan of care based on nursing assessment and diagnosis that prescribes interventions to attain expected outcomes. This includes identifying the holistic needs of the patient, treatment decisions and priorities. Identifies community resources needed for continued care and makes referrals.
  • Implementation: Implements the plan of care and the nursing interventions for the patient by writing nursing orders, giving direct care, assisting with care, determining the responsibilities that can properly and safely be assigned or delegated, providing an environment conducive to safety and health, communicating interventions and responses to other members of the health care team and executing the regimen prescribed by a licensed practitioner.
  • Evaluation: Evaluates the responses to nursing interventions by documenting and communicating evaluation data to appropriate members of the health care team, utilizing data as a basis for reassessing client health status, measuring outcomes and goal attainment, modifying nursing diagnoses, revising strategies of care and prescribing changes in nursing interventions.
  • Documentation: Thoroughly documents patient information in an accurate and timely manner, according to organizational policies, procedures and guidelines.
  • Patient Education: Assesses patient needs and designs, implements and evaluates a teaching plan specific to individual needs or patient groups.

Age Related Competencies
  • Applies knowledge of growth and development in customer interactions and adapts care according to patient's age/developmental stage.
    The incumbent may provide work direction to other support staff.

    Physical Requirements:
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