Health Coach

• Excellent customer service skills. Ability to work with various departments within the hospital system as well as external resources.
• Provides education and counseling for individuals and groups with chronic disease, as well as for preventive health, under the direction of nursing, providers, site leadership, and ambulatory administration

•  Serves as the point of contact in the transition of patient care from ED or hospital discharge back to primary care. Documents education in the patient's EMR.
• Performs the screening for provider review of behavioral health and substance use problems, including depression, alcohol abuse, substance abuse, and smoking status using a validated tool within the EMR.

• Alerts nursing or the provider about patient issues that may be identified during sessions, via the EMR or in person, and documents such matters.

•  Proactively conducts outreach to patient populations and identifies patients with care gaps.

• In collaboration with the healthcare team, identify patients who require follow-up regarding chronic health maintenance, preventive care, no-shows, or other matters. Contact the patients and document the outcome of this intervention in the EMR.

• Schedule appointments for patients based on outreach activity or follow-up interventions.

• Tracks and follows up on test results to ensure the patient and caregiver take appropriate next steps as needed.

• Tracks and follows up on test results to ensure the patient and caregiver take appropriate next steps as needed.

• Attend daily huddles with the health care team.

• Identify barriers to care and direct the patient to the appropriate source for assistance.

•  Collect and maintain statistics regarding interventions with the patient and work with the appropriate source to create meaningful reports.

• Report health interventions and trends as required.
• Perform community health outreach as directed, either to specific patients or at health outreach events.

•  Demonstrates excellent customer service, professionalism, and sensitivity towards patients and coworkers.

•  Work on special projects or health initiatives as assigned.

• Works with the DSRIP team and the PI to impact positive outcomes

• Excellent communication skills, able to effectively engage patients

• Works independently with guidelines provided. 
• Acts as an integral member of the health team

•  Report on and work to improve processes in conjunction with the ambulatory health team continuously.

• Acts as a liaison and patient advocate to promote positive patient outcomes.

•  Recognizes the need for considerate teamwork and facilitates the concept with others

Formal Education and Job-Related Experience: This position requires a minimum formal education of a High School Diploma or equivalent and a minimum of 3 years of job-related experience.

 Desired (not required) criteria include:  Bachelor's degree preferred. Experience in EMR preferred.

 Comments: Health maintenance and outreach experience.  Experience with population health management.   Experience in a health-related field with direct patient contact/customer service. Excel, Word – ability to create tracking.