RN-Health Coach and Remote Patient Monitoring

The mission of Faith Health is to serve Christ by providing all people with exemplary medical services in an environment of love and care. As a provider-led multispecialty healthcare team, Faith Health Physician Services is committed to delivering high-quality, comprehensive services to the people of Northeast Nebraska.

The Health Coach/ Remote Patient Monitoring Nurse is responsible for assessing, planning, implementing, and evaluating patient care. Ultimately responsible for documentation of interventions, outcomes, discharge plans, and patient/family education. Collaborate with physicians and other members of the interdisciplinary health care team to provide continuity of care.

The Health Coach/ Remote Patient Monitoring Nurse is responsible for the direction and assignment of nursing interventions that may be performed by others and is responsible for the coordination and integration of Remote Patient Monitoring services into a patient’s plan of care, capture clinical data key to outcome management, and serves as a clinical resource in disease management. The Health Coach/ Remote Patient Monitoring Nurse works cohesively and collaboratively with providers and other interdisciplinary health care team members to provide high quality and safe care.

Works directly with patients on goal setting, self-management of chronic diseases, and ensuring patient accountability toward reaching their personal goals. The Health Coach/ Remote Patient Monitoring Nurse must have a current Registered Nurse (RN) license. The list of job duties contained in this job description is not all inclusive.

Duties may be added or subtracted at any time due to the needs of the organization. Essential Job Duties and

• 1. Demonstrates ability to appropriately modify approach and procedures to meet needs of age/diversity of population served for the following age groups: Adult (18 years – 65 years) Geriatric (over 65 years)
• Incorporates cultural considerations in the provisions of care.
• Knowledge of growth and developmental stages.
• Considers life changes/effects on health beliefs and behaviors.
• Provides necessary safety measures.
• Provides information and involves family/caregiver in decision making. 2. Performs all responsibilities/duties required by Faith Health as defined in the scope of practice, to assure that the unique nature of the patient is addressed. This includes, but is not limited to, the age of the patient served.
• Consistently demonstrates competent use of the nursing process to assess, prioritize, formulate, implement, evaluate and adapt the interdisciplinary plan of care to meet the patient's age-specific needs.
• Provides information and involves family/caregiver in decision making as appropriate.
• Cleans and processes remote monitoring equipment.
• Includes and communicates the plan of care to patient, family, significant others and relays pertinent information through appropriate documentation and referral to other health care team members.
• Records information on the patient record in accordance with charting and regulatory guidelines.
• Recognizes changes in patient status based on interpretation of assessments, communicates with healthcare team and carries out providers orders accordingly within scope of practice.
• Appropriately utilizes a triage process for patient call-ins with appropriate documentation.
• Uses available teaching aids to implement teaching plan for assigned patient/family and revises the plan based on evaluation of effectiveness.
• Assesses patient/family level of understanding of their rights and responsibilities as healthcare consumers, identifies education needs and includes them in decision making.
• Demonstrates the ability to problem solve and implement solutions. 3. Performs Health Coach Duties as well as Remote Patient Monitoring Duties:
• Coordinate with case managers, physicians and APC’s to identify patients who would benefit from Remote Patient Monitoring
• Train patients and support staff in the use of the Remote Patient Monitoring units
• Oversee and complete patient monitoring and telephone triage for enrolled patients
• Coordinates care for enrolled patients
• Management of the Remote Patient Monitoring systems
• Educates patients and their support persons on chronic conditions and related medications.
• Works with patients and their support persons on self-management including setting short and long-term goals for self-management of chronic diseases, including the assessment of barriers, risks, and educational opportunities.
• Coaches and encourages patients and their support persons on healthy lifestyles, physical activity, and healthy eating/diets.
• Collaborates with patient’s primary care providers (PCP), specialty providers, Registered Dietician, Nebraska Department of Health and Human Services, and other pertinent community resources as necessary to provide continuity of care for patients. Essential Organizational Duties and

• 1. Promotes organizational mission, vision and values. Demonstrates respect and regard for the dignity of all patients, families, visitors, and co-workers to ensure a professional, responsible and courteous environment. Maintains a high level of professional responsibility and performance outlined in Faith Health Performance Standards. Promotes effective working relationships and works effectively as part of a department team (inter- and intradepartmental) to facilitate the department’s/clinic’s ability to meet its goals and objectives. 2. Maintains current knowledge/certification/licensure per organization policy. Pursues professional growth and development.
• Practices within legal boundaries of Nurse Practice Act and according to organization policy and procedures. Attends continuing education programs in order to maintain licensure. Attends organization sponsored training programs as required.
• Maintains certifications as determined by department/clinic policy.
• Completes and maintains pertinent certifications/licenses through continuing education related to diabetes self-management education and support.
• Completes education on diabetes specific tools including but not limited to continuous glucose monitors (CGM’s) and insulin pump delivery systems. 3. Functions as role model for current and new staff.
• Facilitates problem resolution among coworkers as observed by management and peers.
• Demonstrates a constructive approach during all interactions with coworkers and management toward the organization.
• Promotes the profession of healthcare workers in the community.
• Presents neat appearance in proper attire and identification as required by the position, department and the organization.
• Continuously displays a positive attitude within the department/clinic and across departmental lines to contribute to the overall customer service program.
• Serves on committees and assists with programs of the hospital to constantly improve the quality of health care and promote good public relations. 4. Completes all required safety training programs and can describe his or her responsibilities related to general safety, department/service safety, and specific job-related hazards. 5. Understands and adheres to Faith Health Corporate Compliance Plan, Personal Conduct Policy, Safe Environment policy, Grievance Process, Confidentiality, Safety & Security, Infection Control, HIPAA and other departmental and organizational policies, procedures and guidelines. 6. Must be able to remain awake and alert during working hours. Physical presence at the facility is required during scheduled working hours to perform job functions. Work in a timely manner, within the time allotted for the shift per census count. 7. Performs other duties as assigned. Hours will follow clinic hours Monday-Friday 8-4:30. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodation may be made to enable individuals with disabilities to perform the

. Job

The requirements listed below must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. EDUCATION (Minimum Requirements for Position): Required Preferred Graduate of an accredited school of nursing ☒ ☐ CERTIFICATES, LICENSES, REGISTRATIONS: Required Current Registered Nurse (RN) license or temporary permit from the State of Nebraska Basic Life Support (BLS) obtained within one full month from date of hire (Travelers-required upon hire) Previous Experience

Required Preferred Previous clinical experience ☐ ☒ Skills/Knowledge

SKILLS (If Applicable): Required Preferred Language Skills – Ability to read, write, speak, and understand ☒ ☐ the English language. Computer Skills – Ability to use computers and related ☒ ☐ technology efficiently Time Management – Ability to manage time and tasks efficiently ☒ ☐ Interpersonal Skills – Ability to socially interact and communicate ☒ ☐ with others in a positive and professional manner KNOWLEDGE (If Applicable): Required Preferred Patient rights, safety practices, infection control practices ☒ ☐ and risk management principles Other Certifications/Requirements Required Current, valid driver’s license issued in the state of legal Residence Current, Health Coach Certification obtained from an accredited ☒ ☐ Program within one year of hire.