RN Health Coach Clinic

The RN Health Coach (HC) assists with the coordination of patient care across the continuum by collaborating with physicians, Advanced Practice Providers, staff and other professionals. The RN HC is a liaison with specialty practices, in-patient facilities, and serves as a link to community resources.  Works with the clinical team and manages the disease registries by identifying and following up with patients not meeting clinical goals, based on evidenced-based, approved Clinical Practice Guidelines.  May assist or conduct the pre-visit chart review to prepare for a comprehensive patient visit by identifying preventive health care needs based on the approved guidelines.  Works with patients and families, using education, goal setting, action planning, problem solving and motivational interviewing to support health behavioral change. Supports quality improvement and transformation of the health care delivery system. Demonstrates excellent communication skills, independence, assertiveness and critical thinking when working with patients, co-workers; and contributes leadership to the healthcare team. Works autonomously and independently with little direction. Able to facilitate groups and implement projects. Has strong organizational skills.   Demonstrates and applies continuous quality improvement knowledge and skills.  The RN HC will practice nursing in accordance with the North Dakota Nurse Practice Act and the limitations of their scope of practice

• Provides patient support for preventive maintenance and chronic disease management of the following departments/programs/individuals
• Assesses patients emotional status, cognitive status, and learning readiness within the patients environment to augment the holistic plan of care

• Collaborates with community resource persons to deliver services that promote quality outcomes and continuity of care

• Assumes the patient advocacy role to identify and resolve issues with in the healthcare delivery system.  Collaborates routinely with primary care provider and interdisciplinary team regarding patients progress and changing needs  

• Effectively utilizes nursing process to manage patients with chronic diseases

• Effectively provide education to patient and families to meet specific disease related goals 

• Collaborates with internal performance leaders and value based program leaders to support, implement, review, share and submit performance metrics 

• Effectively utilizes disease registries to identify patients with gaps in care 

• Provides safe patient transitions and hand offs through effective communication with patient, family, and RN or other care provider

• Demonstrates accountability by serving as a team member providing coaching/mentoring/training  applicable staff as a nurse

Graduate of a Registered Nurse program

Current license as a Registered Nurse in the state of ND

Preferred 2-3 years hospital or clinic setting, RN Health Coach certification or completion within 18 months of hire

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.