RN Clinic Health Coach

* At time of patient discharge, initiates and completes the TOC process.  + Medical Home does not complete the TOC process.
* Serves as key point of contact to coordinate care with physicians and care team: develops and documents care plan.
* Assists patient with psychosocial needs; helps patients access benefits and community resources.
* Connects patients using ED for non-acute needs with primary care, non-clinical assistance and promotes right site utilization.
* Provides self-management support; may offer disease specific guidance (e.g., Diabetes, CHF, COPD, Pneumonia, etc.)
* Manages patients' discharges from an in-patient facility and ED, by providing outreach to the patient, including medication reconciliation, and provides ongoing follow up as needed.
* Successful completion of annual mandatory education requirements.
* Graduated of an accredited school of nursing required, Associate of Science in Nursing (ASN).
* Bachelor of Science in Nursing (BSN) preferred.
* Knowledge of medical terminology and procedures required.
* Knowledge of medicine including recognizing and diagnosed diseases, deformities, and other illnesses.
* Skill to effectively manage time and prioritize tasks.
* Skill to proficiently type information into the computer to capture or detail information quickly.
* Ability to provide caring patient care services when talking with patients and their family members.
* Ability to critically listen to questions from patients and information from doctors so that you can convey the information effectively.
* Ability to recognize problems early to help avoid bigger problems in the future.
* Ability to problem solve during several daily activities which includes the ability to be flexible.
* Ability to use and navigate through computer programs that contain patient information.
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