Job Description

POSITION SUMMARY:

The Health Coach for Population Health Quality is responsible for providing prospective panel management for patients within the Population Health team’s Accountable Care Organization (ACO) partners. The Health Coach will provide direct patient outreach to promote patient engagement, care coordination and quality metric fulfillment. They may also interface with patient’s case management team and primary care providers, serving as a member of the patient’s care team. Finally, they will help innovate on how we most effectively provide care for this patient population and track impact using data. This role reports to the Director of Quality and collaborates closely with the Medical Director of Quality and other key stakeholders across Population Health and the ACO partners.

Position: Health Coach      

Department: Population Health

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Outreach Efforts

• Direct patient outreach on quality and risk coding gaps
• Appropriately escalates medical or social issues that patients raise during outreach

Care Coordination

• Communicates effectively with patient’s care team including PCP, Pharmacy, and other care team members
• Communicates with patient’s families and/or caregivers when appropriate
• Orders Blood Pressure Monitors and other DME, as needed
• Provides education on how to use at home blood pressure monitors
• Uses a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings. Coordinates with Interpreter Services, as needed.
• Develops and maintains strong relationships with internal and external partners to ensure patient access.

Appointment/Scheduling Support

• Triage patients and schedule follow up, if appropriate, based on blood pressure readings
• Document outreach and schedule appointments following documented workflows as defined by each practice

Workflow Management and Innovation

• Collaborates with Medical Director and Senior Director of Pharmacy, and external partners to define, test, and report on workflows
• Attends meetings with Population Health and ACO leadership aimed at improving performance
• Assists leadership in optimizing existing workflows
• Uses an evidence-based approach to solving systems issues, tracking data when available and appropriate

Tracking and Reporting

• Utilizes dashboard and Microsoft Excel for tracking effectiveness of piloted programs
• Works with large data sets and associated analyses to monitor program effectiveness and adjust processes as necessary

Other Duties

• Provides other administrative and special project assistance as required or assigned by Director of Quality
• Remains knowledgeable of and follows appropriate policies, procedures, and work standards, including but not limited to, policy regarding hours of work, absenteeism, and tardiness.
• Maintains competency in areas of responsibility to ensure quality of care.
• Maintains strict protocols of all confidential or sensitive information
• Attends hospital required and relevant training sessions or activities, as assigned by the Supervisor
• Promotes a positive and collaborative work environment supportive of the hospital’s missions and goals.
• Adapts to changing departmental needs, including but not limited to, offering assistance to other team members, adjusting assignments, and other functions as determined by Director of Quality.
• Assists in orientation/training of new staff members and volunteers.
• Performs other duties assigned or as necessary.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

Bachelor’s degree required

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

None

EXPERIENCE:

3-5 years of experience required; preferably related to project management, social work, nursing or program development.

KNOWLEDGE, SKILLS & ABILITIES (KSA):

• Knowledge of community, social, and health resources
• Empathic understanding of patients
• Expertise in establishing working relationships with patients, their family, professionals, and the community, including the ability to collaborate with a multidisciplinary health care team.
• Computer competency, inclusive of the ability to access and enter data.
• Demonstrated experience with Microsoft Excel
• Ability to understand and interpret complex data analyses
• Ability to work in a fast-paced environment, inclusive of organizational skills, critical thinking, and problem-solving abilities.
• Effective verbal, written, and interpersonal communication skills to facilitate interactions with various members of the health care team, patients, and their families.
• Bilingual or multi-lingual skills (beyond that of English) appropriate to the patient population served, is preferred.
• Demonstrated flexibility with client’s priorities, evolving needs, and goals.
• Sensitivity to ethnic, cultural, gender, and sexual orientation diversity; values; beliefs; and behaviors.
• Demonstrated critical thinking and problem solving ability.

Equal Opportunity Employer/Disabled/Veterans

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