Health Coach RN

1 week ago

Syracuse, New York, United States Trinity Health Full time
Job Title: Health Coach RN

Trinity Health is seeking a skilled Health Coach RN to join our team. As a Health Coach RN, you will play a vital role in supporting patients with chronic or complex diseases and/or high utilization patterns. Your primary responsibility will be to provide support to patients in transitioning across the continuum of care by providing nurse assessment and care planning, education, coordination, and consultation.

Key Responsibilities:
  • Identify high-risk patients through a review of population-based and individual patient information.
  • Provide a baseline patient assessment of patient activation and knowledge, wellness, health behaviors, clinical condition, and medical utilization.
  • Develop a patient care plan to include patient goals, education targets, social supports needed, and recommendations for the clinical care team.
  • Provide individual and group education and coaching that activates patients to enable them to make knowledgeable health decisions and participate more fully in their care.
  • Identify transitional care gaps and coach patients to access appropriate services.
  • Identify needed community and medical services to support patients' goals and coach patients to access them.
  • Facilitate modification to clinical care plans through the clinical care team.
  • Support patient navigators by providing clinical advice and patient communication, where appropriate.
  • Maintain patient registries to identify patients at risk and track outcomes.
  • Track changes in patient activation, health behaviors, and clinical outcomes and identify and implement appropriate interventions.
Requirements:
  • NYS Registered Nurse.
  • Bachelor's prepared in nursing or other clinical field, or clinician with bachelor's or master's in education, health services, or related field.
  • Minimum of two years of experience in primary care, patient coaching, or outpatient case management, etc.
  • Candidates must demonstrate at least one year in providing patient/family education.
  • Training in the Care Transitions Intervention or Transitional Care models a plus.
Working Conditions:

Office/Clinical setting. Exposure Class 1.

Light work: standing, walking, sitting, and lifting.

Pay Range: $30.50-$46.66

Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

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