Purpose of Job
The Health Coach directly supports and promotes the care transitions and social support, and needs of patients' across the continuum of care. Also supports quality and improvement initiatives through targeted outreach to patients who are not meeting clinical goals. The position collaborates with providers, care managers, social workers, and others to facilitate seamless transitions of care, social support interventions, and patient engagement to close care gaps with the goals of assuring superior patient experience and quality outcomes. Identifies high-risk patients, assesses clinical and psychosocial needs, makes referrals to ancillary providers (disease management, palliative care, community organizations, pharmacy, social work, non-clinical services) and develops care plan in coordination with PCP. Engages patients to be active in self-care and personal responsibility.
Successful completion of annual mandatory education requirements.
Graduated of an accredited school of nursing required, Associate of Science in Nursing (ASN).
Bachelor of Science in Nursing (BSN) preferred.
Minimum 1 year patient care experience required.
Current valid license, valid compact multi-state license, or a temporary permit while awaiting licensure required for work state.
Current American Heart Association Basic Life Support (BLS) strongly preferred at time of hire, required within 3 months of hire.
Knowledge of medical terminology and procedures required.
Knowledge of medicine including recognizing and diagnosed diseases, deformities, and other illnesses.
Skill to effectively manage time and prioritize tasks.
Skill to proficiently type information into the computer to capture or detail information quickly.
Ability to provide caring patient care services when talking with patients and their family members.
Ability to critically listen to questions from patients and information from doctors so that you can convey the information effectively.
Ability to recognize problems early to help avoid bigger problems in the future.
Ability to problem solve during several daily activities which includes the ability to be flexible.
Ability to use and navigate through computer programs that contain patient information.
Medium Work - Exerting up to 50 pounds of force.
Occasionally Performed (1%-33%):
Frequently Performed (34%-66%):
Constantly Performed (67%-100%):
Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)
Radiation Alpha, Beta and Gamma (particles such as X-Ray, Cat Scan, Gamma Knife, etc)
Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
Explosives (pressurized gas)
Chemical agents (Toxic, Corrosive, Flammable, Latex)
Biological agents (primary air born & blood borne viruses) (Jobs with Patient contact) (BBF)
Mechanical moving parts/vibrations
Essential Job Functions
Essential Functions I
Navigates high-risk patients across the continuum.
Serves as main point of contact for patients and providers across care settings.
Aims to better manage patients in ambulatory setting and reduce acute care and ED use.
Develops patient care plans with interventions and goals appropriate to patient needs.
Works collaboratively with both internal and external entities to facilitate seamless transitions of care across the continuum by adhering to clinic standards.
At time of patient discharge, initiates the TOC process.
Serves as key point of contact to coordinate care with physicians and care team: develops and documents care plan.
Assists patient with psychosocial needs; helps patients access benefits and community resources.
Connects patients using ED for non-acute needs with primary care, non-clinical assistance and promotes right site utilization.
Provides self-management support; may offer disease specific guidance (e.g., Diabetes, CHF, COPD, Pneumonia, etc.)
Manages patients' discharges from an in-patient facility and ED, by providing outreach to the patient, including medication reconciliation, and provides ongoing follow up as needed.
Utilizes motivational interviewing skills to promote patient engagement and activation.
Assesses conviction, motivation and confidence.
Patient identifies problems and solutions.
Identifies next actions and follow-up.
Works with patients and families on self-management.
Patient sets goals for improving health.
Assesses readiness and importance of change.
Assesses patient motivation and confidence in making successful change.
Patient creates a plan for change by identifying barriers and a plan to overcome them.
Coordinates care across the care continuum.
Coordinates the office care team.
Communicates lab and other tests results to patients in collaboration with provider and other office staff.
Uses professional nursing processes to assess the needs of patients and families calling or presenting for care in the physician office.
Easy point of contact for patients.
Liaisons with Specialty Care Offices.
Links to community resources.
Involvement in Quality Improvement (QI) activities.
Initiates improvement projects in their clinics.
Meets bimonthly with other Health Coaches to continually share best clinic practices and successes.
Monitors Quality measures.
Coordinates completion of payer gap lists.
Manages diabetic quality measures.
Provides appropriate care specific to the age of the patient to ensure understanding and comfort level of treatment as outlined in the "Age Specific Criteria".
Essential Functions II
Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.
Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures.
Other duties as assigned.