Clinical Health Coach

Job Description

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Provides professional RN health coaching for patient self-management. Oversees clinical care implementing clinical consensus guidelines. Promotes care coordination and care transitions to connect the care continuum. Improves communication with patients using styles adapted to unique patient needs.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and /or ability required.

• Responsible for being a patient advocate with physicians and other healthcare providers.
• Performs in the role of the Clinical Health Coach to empower patients in self-management.
• Employs guiding principles of coaching including, but not limited to appreciative inquire, reflective listening, change talk, stages of change, and motivational interviewing.
• Utilizes population health strategies to address chronic care needs or risk factor reduction for all patients who may benefit from health coaching and care coordination.
• Advocates disease prevention, health and promotion of healthy lifestyles.
• Uses guiding principles of coaching including, but not limited to appreciative inquiry.
• Oversees the disease database including:
  -Assure database is kept up to date.
  -Identify patients overdue for visits, labs, or referrals.
  -Arrange for follow-up services as appropriate.
  -Identify patients not meeting clinical goals, such as BP control, glucose control or nutritional goals, and arrange for follow-up services by protocol or as appropriate.
  -Create patient, physician, and clinic level quality performance reports.
• Conducts pre-visit chart review of chronic care and Medicare wellness patients including:
  -Identification of all needed preventive health maintenance, immunizations, and chronic disease interventions.
  -When standing orders allow it, order or complete interventions prior to the patient seeing a provider.
  -Fill out pre-visit forms or initiate office visits forms to communicate the review to the provider.
• Perform Accountable Care Organization tasks, including chart audits, preventative care coordination and education, chronic care management as identified in active measures and actively assists with gap report closure.
• Works with patients and families on Self-Management Support including:
  -Set short and long-term goals for self-management of chronic disease.
  -Address medication adherence in patients not meeting outcome goals.
  -Assess and work on the patient’s readiness to change, the importance of change, and confidence in ability to change.
  -Help the patient to identify and overcome barriers.
  -Make a plan for follow-up between visits.
  -Provide or arrange needed patient education regarding specific health care skills and general disease concepts.
  -Assist with shared medical appointments when necessary.
  -Communicate face-to-face in the office setting, by telephone, or thru the patient portal.
• Coordination of Care across the care continuum including:
  -Assist as a liaison with patients and their families to physicians, clinical staff, and other departments.
  -Act as a liaison with hospitalized patients and the clinic.
  -Follow-up with patients by phone shortly after hospital discharge and complete transitional care management (TCM) documentation and billing.
  -Act as a liaison with specialty clinics, hospital, long term care and ER for patients under review of the Clinical Health Coaches.
  -Proactively act as a patient advocate, responding to and working to resolve patient concerns.
  -Providing a link and patient education to community resources.
• Involvement in QI activities:
  -Communicates and coordinates with the health-care team (including management, providers and other health nurses if applicable) in the development of tools for optimal patient outcomes and report findings.
• Assist in the ongoing Patient Centered Medical Home (PCMH) recertification efforts.
• Provide education for the community through health fairs, speaking at local organizations, and seminars.
• Practice the proper fire, safety and disaster procedures as set forth by SMC.
• Participate in all quality, safety, security and infection control programs that are mandatory as well as those required and provided by the department.
• Uphold confidentiality and HIPAA compliance at all times and report violations to the Privacy Officer.
• Understand and comply with the requirements of the Saunders Medical Center’s Compliance Program, including, but not limited to the Code of Conduct, the Compliance Policy, all Saunders Medical Center-wide policies for compliance, and compliance plans affecting specific duties and responsibilities.
• Participate in all education and training programs regarding compliance as required by Saunders Medical Center policy and as requested by the Supervisor.
• Maintain a professional environment.
• Maintain all professional certification and/or licensure requirements.
• Participate in quality assurance and performance improvement projects.
• Provide education to physicians and related departments regarding process changes for patients.
• Demonstrate personal traits of a high-level commitment, motivation and energy; team orientation; professionalism; trust; personal honesty and integrity; and a demonstration of placing others in a place of high value and treating them with dignity and respect.
• Perform nursing tasks as needed such as: injections, immunizations, finger stick blood glucose testing and dressing changes.
• Other duties as assigned.

Supervisory Responsibilities

None.

Disclosure Statement

The above statements reflect the general details considered necessary to describe the essential functions of the job as identified, and shall not be considered as a detailed description of all work requirements that may be inherent in the position.

Education and/or Experience

Graduate of an accredited nursing program; a Registered Dietitian or other closely related health care field.

Three years clinical experience desired.

Certificates Licenses, Registrations

Current Nebraska Nursing License or Registered Dietitian and/or Licensed Medical Nutrition Therapist

Current Basic Life Support Certification

Clinical Health Coach Certification or able to obtain within 6 months of hire

Language Skills

Must be able to read, write and follow written and oral instructions and possess positive skills in communication. Ability to deal tactfully with personnel, patients, visitors, and the general public.

Mathematical Skills

Ability to calculate at the level necessary to perform essential duties of the position.

Reasoning Ability

Ability to make independent decisions when circumstances warrant such action. Ability to interpret a variety of instructions furnished in oral, written, diagram or schedule form.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee will sit most of the time. The employee must sit, reach with arms and hands and occasionally lift 50 pounds. The employee must occasionally walk and climb or balance.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position. Attendance is essential and required for a successful working environment.

Typical office environment with periods of time spent in patient care areas.