Job details
Job type full-time
Full job description
The rn condition care health coach coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resource outcomes.
Serve as a team member on a health care coordination team that monitors gaps in evidence-based care or potentially inappropriate utilization among members with select chronic conditionsMake outreach to members with newly identified chronic conditions or rising risk for complications from chronic conditions, facilitate appropriate health care service delivery and improve the quality and cost efficiency of care and service.
Perform assessments over the telephone of the member’s health status, health literacy, and level of support needed to reduce barriers to evidence-based careThe assessment may include condition specific issues, clinical history, medications, cultural and linguistic needs, caregiver support and resourcesAdditional outreach and education may be provided through our digital management tool with secure direct messaging with members through the application.
In collaboration with the member, develop a self-management plan tailored to member’s needsIdentify and address barriers to meeting goals or compliance with plan of care.
Provide appropriate referrals with supporting documentation to case management, registered dietician, social work, pharmacist and/or behavioral health case management.
Work with the member`s physician, pharmacist or caregivers to ensure coordination of care and to overcome barriers to care.
Work with members with chronic conditions that are at rising risk for high cost and/or inappropriate (over or under) utilization of servicesEncourage pro-active intervention to limit expense and encourage positive outcomes.
Maintain awareness of community resources and fundingUtilize resources and funding sources as appropriate.
Collaborate with primary care physician, pharmacist, case managers, the member, family members and other members of the health care team to develop and/or coordinate plans of treatment.
Obtain consents as indicated.
Complete documentation of calls and other outreach.
Analyze, track and report condition care activity according to department policy.
Hiring requirements
Rn diploma, rn associate’s degree or bachelor’s of science in nursing (bsn) degree.
Minimum of 3 years full time direct clinical experience in an acute medical or acute surgical setting.
Proficiency with a microsoft windows operating system, including excel.
Must have valid license to practice nursing within the us and have started application for nc nursing license.
Requires one evening shift (11:00am-7:30pm) per week and approximately 2 half-day saturday shifts (9:00am to 1:00pm) per year.
Hiring preferences
The incumbent must possess medical management/clinical decision-making skills and sound skills in assessing, planning, and managing member care
Experience working with members with chronic condition and/or disease management programs or services.
Confidence with using digital technology applications.
Advanced assessment and teaching skills.
Problem solving skills.
Familiarity with legal terminology and liability issues and ability to handle ethical or risk management issues.
Quality management/outcomes experience preferred.
Previous work experience with a managed care organization or provider is also preferred.
Excellent communication and interpersonal skills with all levels of internal and external customers necessary.
Individual must be self-motivated/self-directed.
Must possess the ability to work independently, demonstrate effective time management skills, and to prioritize effectively.
The ability to deal effectively with change within the unstructured nature of care management and remain focused.
Demonstrates creativity, critical thinking, counseling, interviewing, negotiating, and research skills.
Bilingual (spanish and english) preferred.
Multi-state license preferred.
