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CommonSpirit Health RN - Episodic Health Coach in DES MOINES, Iowa


MercyOne is a connected system of health care facilities and services dedicated to helping individuals live their best life.

With 420 care locations, our clinics, medical centers and affiliates are never too far from home, allowing us to improve the lives of individuals and communities across the state of Iowa and beyond.


Job Summary:

The RN Episodic Care Management Health Coach virtually provides care management and care coordination services for a 90 day episode for Population Health patients enrolled in the PHSO’s Episodic Care Management/Care Coordination program. This role uniquely blends for job duties of the RN Transition Health Coach, the RN Ambulatory High Risk Health Coach and possibly the RN Post-Acute Health Coach for a defined 90 day episode that begins with the a qualifying discharge from the acute level of care. Upholds and supports PHSO standard workflows and procedures at accreditation level quality.

Essential Position Expectations:

  • Performs patient identification and risk stratification following the PHSO’s Episodic Care Management Protocol.

  • Manages the timely transitions in care following a qualifying acute care discharge:

  • Requests documents from outside facilities needed to support care transition discussions.

  • Confirms PCP and/or specialist follow-up appointments and collaborates with primary care provider team and others to schedule follow-up appointments if they have not been scheduled at time of transition

  • Completes medication reconciliation/medication adherence assessments

  • Reviews red flags as appropriate

  • Reviews discharge instructions

  • Completes resource referrals and performs follow-up to ensure resources met needs.

  • Extends transition services as needed to prevent/reduce further unnecessary Post-acute or acute care utilization.

  • Manages the utilization of all post-acute facility admissions

  • Manages the ongoing care coordination services following discharge back to the community setting for the 90 day episode:

  • Provides at least a monthly engagement conducted either by phone, virtually or in person

  • Completes routine assessments of physical, mental, social and functional needs

  • Develops, implements, and updates patient care plans

  • Manages coordination and communication across providers, services, and markets

  • Assess for adherence, barriers and gaps in recommended care

  • Facilitates advance care planning discussions and the completion of advance directives for patients ≥ 18 years of age

  • Manages transitions in care following hospital discharges, emergency department use and post-acute stays.

  • Applies motivational interviewing and teach back during interactions with patients.

  • Provides coaching and education to support self-management.

  • Participates in quality improvement, measurement and data collection to include populations with clinical and financial risk.

  • Delegates to support team such as community health workers as appropriate.

  • Informs primary care provider of ongoing care management activities, patient progress and changes in the patient’s health status

  • Supports quality reporting for population health contracts.

  • Refers high risk-acuity patients to the RN Ambulatory High Risk Health Coach when further care coordination services are required beyond the 90 day episode.

  • Collaborates with the appropriate Provider to answer patient questions and concerns that fall outside of scope.

  • Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day.

  • Understands accountability for results and self-manages to support PHSO level success goals in the areas of quality, cost of care and patient experience.

  • Upholds and supports PHSO standard workflows and procedures at accreditation level quality.


Education: Graduate from an accredited school of nursing. BSN preferred.

Experience: Minimum of 3 years previous nursing experience. Varied clinical experience preferred.

Certifications & Licenses: Iowa state licensure as a Registered Nurse. Basic Life Support required (BLS).

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Requisition ID 2021-173708

Employment Type Full Time

Department Case Management - Population Health

Hours / Pay Period 80

Shift Day

Standard Hours Monday - Friday (8:00 AM - 5:00 PM)

Facility / Process Level : Name MercyOne Des Moines Medical Center


Equal Opportunity CommonSpirit Health™ is an Equal Opportunity/ Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law.