Clinical Health Coach
4 weeks ago
**Description**:
***PRIMARY ACCOUNTABILITIES**:
- Quality/No Harm:
- Works with care teams and technology to identify high-risk, high-need patients by helping to implement best practice processes for preventative services, chronic care and disease management
- Act as the liaison between the patient, the patient support network, treating physician(s), and ancillary providers utilizing a multi-disciplinary approach to assess, identify, plan, health goal setting and measure optimal clinical outcomes
- Provide face-to-face and/or telephonic coaching, support and education.
- Utilize motivational interviewing and engagement strategies to support overall health, wellness of patients and self-management which includes employing behavior change/motivational interviewing skills to assess readiness, health goal setting short and/or long term needs, engage patient's plans for change following standard policy and procedures, clinical guidelines and national evidenced-based criteria
- Educate and refer patients to available health resources when appropriate.
- Provide support to patients in order to help them identify a need for behavior change to improve health status, reduce health risks and improve quality of life.
- Follow up with patients to ensure that patient engagement has been achieved and assess future educational and/or program referral needs.
- Implements coaching plan by using behavior change principles to identify member barriers and develop ways to overcome those barriers.
- Document interactions and interventions as directed with health technology tools.
- Support clinical integration and collaboration on patients’ care plan in conjunction with other health professionals
- Stewardship:
- Provides health coaching activities across the continuum of care in order to facilitate and promote high quality, cost-effective outcomes, focused on the whole patient orientation and self
- management decision support and aims to minimize any fragmentation of health care delivery.
- Supports system-wide efforts pertaining to alternative payment models and reductions in Medicare Spending (MSPB)
- Identify cost savings options for patients
- Addresses/resolves system problems impeding diagnostic or treatment progress.
- Proactively identifies resolves or escalates delays and obstacles.
- Demonstrates understanding of level of care criteria and reimbursement factors for home care, rehabilitation, outpatient treatment, residential treatment and long term care in development of discharge plans. Seeks alternatives to discharge planning, and creates relationships with all supportive organization to help in the discharge process.
- Customer Experience:
- Demonstrates positive customer relations in all settings and circumstances.
- Demonstrates strong I-CARE values
- Possess strong empathy skills and able to develop strong rapport with patients
- Demonstrates effective communication with other members of the healthcare team and promotes effective team functioning.
- Provides patient, family, and/or caregiver education as directed by the plan of care.
- Provides service to patients and families with sensitivity and respect for their needs, expectations, age, cultural, and individual differences.
- Works with the physician advisor, physicians, nursing, ambulatory programs, outpatient programs, interdisciplinary team and health plan for defined patient populations to develop clinical appropriate transitional pathways, continuum care management for patient care and patient satisfaction.
- Coordinates/facilitates patient care progression. Review discharge needs at time of admission, and assists with the transition of care through hospital say and discharge
- Works collaboratively and maintains active communication with physicians, nursing, physician advisor, and other members of the interdisciplinary care team to effect timely, appropriate patient resource management, and patient transition.
- Seeks consultation from appropriate disciplines/ancillary departments as required to expedite care and facilitate patient transition.
- Demonstrates positive customer relations in all settings and circumstances.
- Promotes patient's independence by establishing patient care goals; teaching and counseling patient, friends, and family and reinforcing their understanding of disease, medications, and self-care skills.
- Provides information to patients and health care team by answering questions and requests.
- Resolves patient needs by utilizing multidisciplinary team strategies.
- Promotes and restores patients' health by developing day-to-day management and long-term planning of the patient's self-care.
- Directing and developing staff; collaborating with physicians and multidisciplinary professional staff.
**Qualifications**:
**MINIMUM QUALIFICATIONS**:
- Education: A Bachelor degree or higher in health-related field (i.e. health promotion, public health, nutrition, kinesiology, exercise science, nursing, etc.).- Bachelor Degree in relevan
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