Health Coach RN

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• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance and medical coverage at 100% (after deductible) when utilizing a Duly provider.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

• Full‑Time, 40 hours/week
• Hours:
  
  Monday 8:00‑4:30 PM;
  Tuesday 10:00‑6:30 PM;
  Wednesday‑Friday 8:00‑4:30 PM;
  No weekends.

• Keeps an accurate registry of the patients assigned to his/her panel utilizing EPIC tools such as reporting workbench and runs daily, weekly and monthly reports to keep patient care tasks and follow‑up on schedule.
• Receives daily updates of patient information such as blood glucose, daily weights, etc., compares the patient information to the normal values and takes action on the information according to the approved protocols. When the protocol does not apply, seeks guidance from the Supervisor/Clinical Manager, the APN or the PCP. Actions may include facilitating lab‑work or diagnostic testing, scheduling an office visit or home assessment or other actions.
• Contacts the patient to assess the patient's achievement of self‑management goals, notes obstacles and/or new issues the patient is experiencing and works with the patient to address the obstacles or issues through the use of motivational interviewing skills. Presents the contact assessment and discussion to the clinical team at the patient care conference. Incorporates new interventions into the plan of care as determined by the clinical team and works with the patient to implement these changes.
• Makes appointments for specialty care, lab‑work and/or diagnostic testing as needed by the patient and on schedule according to protocols, clinical pathways/guidelines and the patient's plan of care.
• Provides patient instructions and performs patient teaching according to approved protocols. Seeks the assistance of the Supervisor/Clinical Manager, APN or PCP for instructions and teaching outside of the protocols.
• Patient Phone Calls:
  Takes phone calls from patients regarding urgent issues and takes action based upon appropriate clinical protocols. When protocol does not apply seeks guidance from the Supervisor/Clinical Manager, the APN or the PCP.
• Patient Orientation:
  In conjunction with the clinical team, plans and conducts New Patient Orientation for patients coming into his/her panel.
• Patient Care Conferences and Clinical Improvement:
  Participates in the daily patient care conference and QI sessions with the clinical team.
• Case management:
  Together with the patient, develops individualized care plans to assist the patient in meeting self‑management goals. Documents initial assessment and all follow‑up patient care contact according to National Committee for Quality Assurance (NCQA) guidelines.
• Transition of Care:
  Prior to hospital discharge, obtains essential clinical information for the BCC team. Ensures coordination and continuity of care as patient is discharged from hospital to home, home with home health or to extended care facility. Documents all information utilizing transition of care tools. Assists patient and family in making follow‑up appointments and diagnostic testing.
• Patient and Appointment Preparation:
  Gathers all pertinent information prior to patient visit and prepares for review by clinical team. Completes the Pre‑visit planning sheet if applicable. Prepares examination rooms for patient visits, including cleaning, sterilizing, stocking supplies. Escorts patients to exam rooms and assists in obtaining pertinent information, which may include obtaining vital signs, weight, height, health history, and symptoms.
• Administers intravenous (IV) medications and IV fluids. Assesses monitors and documents patient response to medications and…