Community Health Coach

Position Summary Responsible for providing telephonic and/or face to face-based education and care management for in-patient and out-patients with chronic diseases and their caregivers. Assisting patients with resources and support needed to manage their disease process in such a way that decreases their risk for complications, emergency room visits and hospitalizations. Properly document patient interactions as part of the patient#s care team. Perform home visits within a timely fashion after inpatient or emergency department discharge. Take responsibility; keep commitments; complete tasks on time. Volunteer readily; take independent actions; ask for and offer help when needed. This position may support Center for Family Medicine (CFM) and all RHP aligned providers. # Minimum Requirements Education

Bachelors Required Experience N

/A Required License/Registration/Certifications Must maintain a valid US Driver#s License with vehicle insurance and good driving record # Preferred Requirements Preferred Education

A certification in a health

-related profession or experience in a health-related field such as but not limited to Wellness Coach, Health/Diabetes Educator, Community Health Worker, Paramedic/EMT, or Social Work. Preferred Experience

Hospital

/Healthcare Experience Home Visit Experience Case Management Experience Preferred License/Registration/Certifications N/A # Core Job Responsibilities Actively manage members identified as moderate to high risk after inpatient discharge in order to reduce readmissions and unnecessary ER visits. Complete the documentation necessary in Epic to facilitate communications to the patients# primary care physician and billing for Transition Care Management (TCM) codes. #Actively engage a panel of adult, pediatric, and/or geriatric patients spanning all payor types. Conduct home visits with members who are moderate to high risk for readmission to reinforce: following the patients# care plan, medication adherence education, disease specific education, improve patients access to care, and help identify any additional health care needs. Provide ongoing monthly education to members identified with two or more chronic diseases ranging from moderate to high-risk complexity. Complete the documentation necessary in Epic to facilitate communications with primary care provider and meet the requirements for billing Chronic Care Management (CCM) codes. Build and maintain positive working relationships with the patients, providers, nurse case managers, agency representatives, supervisors and office staff to help the patient achieve the best possible outcomes. Identify socio-economic issues that affect the patient#s overall health and develop health/social management plans and goals in conjunction with the patients care team. Identify clinical gaps in care and scheduling preventative exams when needed. Assist with patient medication adherence by educating the patient and/or caregiver on current medication list, reasons for medication, and importance of obtaining refills. Proactively collaborate with providers, community resources, and other colleagues to help members achieve the best possible outcomes Provides ongoing follow-up and report compliance to Management as requested. Provides support to management for internal reporting to internal and external stakeholders and employees. Be comfortable with patient education on condition management and/or disease management, not limited to; tobacco cessation, maternity management, various chronic disease states such as, Diabetes, COPD, Cholesterol, heart failure, etc. Educate members on accessing healthcare appropriately and working with their health plan, identifying, and communicating improvement opportunities through coaching. Identify opportunities for intervention to help promote patient compliance and improve clinical outcomes by contacting the members, assisting with appointments, transportation, financial and any other needs. Receive and act upon referrals received from CFM and RHP Physicians. Collaborate with Center for Family Medicine program with Resident shadowing and other duties. Meet with RHP staff regarding patient interventions and report discussion to the complex case review team. Responsible for recruitment, engagement, and retention of patients into the program who are moderate to high risk. Must achieve productivity standards. Must have excellent communication and computer skills. Interact with patients by phone and/or face to face; may be required to meet member in various health care settings, such as physician offices, hospital or home. Properly handles member records to ensure compliance with patient health information applicable to the preservation, accuracy, and completeness of communication and/or retention of patient information, meeting all HIPAA regulations and the HITECH Act provisions as required by law. Must be willing to work outside normal business hours. All other duties as assigned. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or finger, handle, or feel objects, tools or controls. The employee is occasionally required to stand, walk, sit, reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl. The employee may have exposure to load noise. Must be able to sit for an extended period of time. Must be able to walk/stand for extended period of time. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus. This position will require driving a vehicle and completing home visits within a 40-mile radius of SRHS Main Campus Must be able to read and interpret patient discharge instructions at a high school to college level comprehension #

Position Summary

Responsible for providing telephonic and/or face to face-based education and care management for in-patient and out-patients with chronic diseases and their caregivers. Assisting patients with resources and support needed to manage their disease process in such a way that decreases their risk for complications, emergency room visits and hospitalizations. Properly document patient interactions as part of the patient's care team. Perform home visits within a timely fashion after inpatient or emergency department discharge. Take responsibility; keep commitments; complete tasks on time. Volunteer readily; take independent actions; ask for and offer help when needed. This position may support Center for Family Medicine (CFM) and all RHP aligned providers.

Minimum Requirements

Education

• Bachelors Required

Experience

• N/A

Required License/Registration/Certifications

• Must maintain a valid US Driver's License with vehicle insurance and good driving record

Preferred Requirements

Preferred Education

• A certification in a health-related profession or experience in a health-related field such as but not limited to Wellness Coach, Health/Diabetes Educator, Community Health Worker, Paramedic/EMT, or Social Work.

Preferred Experience

• Hospital/Healthcare Experience

• Home Visit Experience

• Case Management Experience

Preferred License/Registration/Certifications

• N/A

Core Job Responsibilities

• Actively manage members identified as moderate to high risk after inpatient discharge in order to reduce readmissions and unnecessary ER visits. Complete the documentation necessary in Epic to facilitate communications to the patients' primary care physician and billing for Transition Care Management (TCM) codes.

• Actively engage a panel of adult, pediatric, and/or geriatric patients spanning all payor types.

• Conduct home visits with members who are moderate to high risk for readmission to reinforce: following the patients' care plan, medication adherence education, disease specific education, improve patients access to care, and help identify any additional health care needs.

• Provide ongoing monthly education to members identified with two or more chronic diseases ranging from moderate to high-risk complexity. Complete the documentation necessary in Epic to facilitate communications with primary care provider and meet the requirements for billing Chronic Care Management (CCM) codes.

• Build and maintain positive working relationships with the patients, providers, nurse case managers, agency representatives, supervisors and office staff to help the patient achieve the best possible outcomes.

• Identify socio-economic issues that affect the patient's overall health and develop health/social management plans and goals in conjunction with the patients care team.

• Identify clinical gaps in care and scheduling preventative exams when needed.

• Assist with patient medication adherence by educating the patient and/or caregiver on current medication list, reasons for medication, and importance of obtaining refills.

• Proactively collaborate with providers, community resources, and other colleagues to help members achieve the best possible outcomes

• Provides ongoing follow-up and report compliance to Management as requested.

• Provides support to management for internal reporting to internal and external stakeholders and employees.

• Be comfortable with patient education on condition management and/or disease management, not limited to; tobacco cessation, maternity management, various chronic disease states such as, Diabetes, COPD, Cholesterol, heart failure, etc.

• Educate members on accessing healthcare appropriately and working with their health plan, identifying, and communicating improvement opportunities through coaching.

• Identify opportunities for intervention to help promote patient compliance and improve clinical outcomes by contacting the members, assisting with appointments, transportation, financial and any other needs.

• Receive and act upon referrals received from CFM and RHP Physicians.

• Collaborate with Center for Family Medicine program with Resident shadowing and other duties.

• Meet with RHP staff regarding patient interventions and report discussion to the complex case review team.

• Responsible for recruitment, engagement, and retention of patients into the program who are moderate to high risk.

• Must achieve productivity standards.

• Must have excellent communication and computer skills.

• Interact with patients by phone and/or face to face; may be required to meet member in various health care settings, such as physician offices, hospital or home.

• Properly handles member records to ensure compliance with patient health information applicable to the preservation, accuracy, and completeness of communication and/or retention of patient information, meeting all HIPAA regulations and the HITECH Act provisions as required by law.

• Must be willing to work outside normal business hours.

• All other duties as assigned.

• While performing the duties of this position, the employee is regularly required to talk or hear.

• The employee frequently is required to use hands or finger, handle, or feel objects, tools or controls.

• The employee is occasionally required to stand, walk, sit, reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl.

• The employee may have exposure to load noise.

• Must be able to sit for an extended period of time.

• Must be able to walk/stand for extended period of time.

• The employee must occasionally lift and/or move up to 25 pounds.

• Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus.

• This position will require driving a vehicle and completing home visits within a 40-mile radius of SRHS Main Campus

• Must be able to read and interpret patient discharge instructions at a high school to college level comprehension