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Health & Wellness Coach (Care Coordinator)

4 months ago

Oakland, United States LifeLong Medical Care Full time

Overview:
Community healthcare is highly rewarding. Come join a dynamic care team at LifeLong Medical Care. We are looking for a **Health & Wellness Coach** at our TRUST Health Center in downtown Oakland. TRUST Health Center’s diverse and unique care team supports health through encouragement, blending medical, mental and social care under one roof. We help people experiencing homelessness in the Bay Area through an intentionally created community where people without their own safe space feel welcomed and accepted. The Health and Wellness Coach provides administrative support to psychosocial services staff and case management services to patients.

This is a full time, 40 hrs/wk, benefit eligible position.

This position is represented by SEIU-UHW. Salaries and benefits are set by a collective bargaining agreement (CBA), and an employee in this position must remain a member in good standing of SEIU-UHW, as defined in the CBA.- Benefits_
- Compensation: $21 - $23/hour. We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including nine paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan._
- COVID-19 Vaccine Policy_
- In accordance with LifeLong Medical Care's commitment to provide and maintain a workplace that is free of known hazards, we have adopted a Mandatory COVID-19 Vaccine Policy to safeguard the health of our employees and their families; our patients and visitors; and the community at large from infectious diseases, that vaccinations may reduce. This policy will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Order of the California State Public Health Officer. Unless a reasonable medical or religious accommodation is approved, all employees must receive COVID-19 vaccinations._

**Responsibilities**:
**Care Coordination**
- Primary Care Coordination
- Tracks patients’ progress and alerts providers to need for enhanced services according to clinic prioritization
- Provides short term case management services
- Assists with patient specific barrier removal
- Eligibility determination to ensure access to community services
- Troubleshooting around medications, transportation, benefits
- Available to provide community accompaniment for vulnerable patients in collaboration with care team
- Tracks, manages, and facilitates specialty referrals to ensure patients successfully follow-up
- Makes appointments and completes reminder calls for primary care provider panel
- Assists with medication reconciliation

2. Integration of Care (Medical and Psychosocial)
- Accepts warm hand offs of patients between Medical and Behavioral Health providers to facilitate integration of care.
- Coordinates behavioral health referrals and collaborates with patient’s community behavior health providers
- Maintains active list of relevant community resources and places appropriate referrals
- Familiar with basic local housing and shelter resources for provision to patients

**Health coaching (patient self-management support)**

1. Coaches patients in self-management (e.g. medication adherence, lifestyle)

2. Assists patients in developing and executing health-related action plans or behavior changes based on client goals

3. Navigates problem-solving with patients as they encounter obstacles to achieving health-related goals

4. Conducts brief interventions with patients regarding alcohol and tobacco use and other behavioral health issues as appropriate.

**Panel Management**

1. Maintains accurate provider panel in Electronic Health Record with active patient definition

2. Maintains chronic disease registries and targets patients for chronic care management activities at regular intervals such as
- Retention in care
- Chronic disease related education referrals
- Chronic disease related preventative tasks (use of standing orders)

**Other Duties**

1. Actively participates in team meetings with internal staff and external partners

2. Contributes to clinic quality improvement planning and implementation

3. Responsible for data collection, entry and generation of reports

4. Coordinates operation of special projects as assigned by Center Manager

Qualifications:

- Strong organizational, administrative and problem-solving skills, and ability to be flexible and adaptive to change while maintaining a positive attitude.
- Ability to prioritize tasks, work under pressure and complete assignment in a timely manner.
- Ability to effectively present information to others, including other employees, community partners and vendors.
- Ability to seek direction/approval from on essential matters, yet work independently with limited onsite supervision, using professional judgment and diplomacy.
- Work in a team-oriented environment with a number of professionals with different work styles and support needs.
- Excellent interpersonal, verbal, and written skills and ability to