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CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S., from clinics and hospitals to home-based care and virtual care services, CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources, CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community.


Job Summary / Purpose

Works collaboratively with physicians, staff and other health care professionals to provide patient-centered, coordinated care across the care continuum. Is an integral member of both the CIN population health care management team and the clinic health care team working towards improved clinical, financial and patient experience outcomes. Is primarily responsible for providing care management services for a panel of patients with poorly controlled or complex medical conditions in the ambulatory (clinic) setting.

Essential Key Job Responsibilities

  • Provides Coordination of Care across the care continuum including:

  • Assisting as liaison with patients and their families to physicians, clinical staff, and other departments.

  • Acting as a liaison with hospitalized patients and the clinic, following up with patients by phone or face to face after hospital/facility discharge.

  • Acting as a liaison with specialty clinics.

  • Proactively acting as patient advocate, responding to and working to resolve patient concerns

  • Providing a link to community resources

  • Provide oversight of the care management platform including:

  • Assuring documentation is kept up to date.

  • Identifying patients overdue for visits, labs, or referrals and arranging for follow-up services as appropriate.

  • Identifying patients not meeting clinical goals, such as BP or glucose control, and arranging for follow-up services by protocol or as appropriate.

  • Presenting patient, physician, and clinic level quality performance reports/metrics.

  • May provide oversight or conduct pre-visit chart review of patients including:

  • Identifying needed preventive health maintenance, immunizations, and chronic disease interventions.

  • Effectively communicates the review to the provider and other key staff as appropriate.

  • Reviews identified insurance care gaps and works to improve the clinical outcomes.

  • Coordinates care transitions for assigned patients.

  • Works with patients and families on Self-Management Support including:

  • Setting short and long-term goals for self-management of chronic disease and other health care conditions.

  • Addressing medication adherence in patients not meeting outcome goals.

  • Working with patient to create a plan for health behavior change utilizing the 5A’s approach

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

  • Helping the patient to identify and overcome barriers

  • Making a plan for follow-up between visits

  • Providing needed patient education regarding specific health care skills and general disease concepts.

  • Assisting with coordination of shared medical appointments.

  • Communicating face-to-face with the patient or care giver, or by telephone, mail or by e-mail.

  • Actively participates in QI activities :

  • Assessing and collaborating with Clinic Managers and Providers on strategies to achieve individual clinic level/patient goals such as quality and efficiency.

  • Actively participating/coordinating committees as needed/requested by the Clinic Manager or Clinic Director, i.e. Performance Improvement Teams.

  • Communicating and coordinating with the healthcare team in the development of tools for optimal patient outcomes and report findings.

  • Meets on a regular basis with other Health Coach, team members as coordinated by the Health Coach Managers for information sharing and continuing education activities.


Minimum Qualifications

Required Education(for CHI Leadership Job Levels from Supervisor through President)

Click to select CHI Leadership Job Level & Required Education

Required Licensure and Certifications

· Possession of a current of compact state license as a registered nurse issued/defined by the State of Iowa.

· Certification as Healthcare Coach or obtained within one year of hire.

· Basic Life Support (BLS) for the Healthcare Provider certified or obtained by the end of the orientation period (approximately six (6) weeks).

· Proof of completion of Mandatory Reporter abuse training specific to population served within three (3) months of hire.

PREFERRED Qualifications

· Clinic/Physician office experience preferred.

· 1-2 years of acute care or home care experience preferred

  • Experience in patient education preferred.

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Equal Opportunity

CHI Health at Home is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected Veteran status or any other characteristic protected by law. For more information about your EEO rights as an applicant, please

If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (1-800-875-2622) and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this telephone number.

Job ID2020-119477

Employment TypeFull Time

DepartmentPopulation Health Management

Hours / Pay Period80





Standard Hours8a-4:30p