Telephonic Rn Health Coach

Essential Functions

• Perform assessment and evaluation of patients with chronic disease per client contractual obligations.
• May Evaluate the needs of individuals and families, obtain psychosocial history; assess needs, and link individuals and families with available psychological, health, and social services.
• Collect detailed information including medical, social, and financial information to aid in facilitating the appropriate treatment plan consistent with the patient’s needs. This may include member interviews, complete assessments, and provide brief psychotherapeutic interventions.
• Collaborate with health care providers and ancillary service providers to validate the appropriate individualized treatment and care plan that may include a person-centered approach to promote wellness, appropriate utilization, awareness, and understanding of condition self-management, and identify educational opportunities.
• Ensure data necessary to report standard measures is collected as discreet data elements in the EHR or disease registry database.
• Work with EHR or registry vendors to obtain data output files in defined formats.
• Actively engage with patients and families, utilizing motivational interviewing techniques.
• Teach self-management skills and supports patients and families with chronic disease.
• Coordinate care management activities across the care continuum. This may include on-the-spot counseling for members with an active mental illness or disability and/or family members patients and staff.
• Coordinate activities across the care continuum and identify gaps in care. This may include transitional care and referrals to appropriate levels of care.
• Implement and teach quality improvement methods including Plan, Do, Study, Act, and use of data to office/clinic personnel and clinicians.
• Ensure appropriate composition of the QI team including clinical champion(s).
• Assemble data and information for regular reporting requirements maintaining confidentiality and sensitivity of protected health information.

Requirements

• Registered nurse (RN) or LCSW in Oklahoma is required.
• Two or four-year degree in health care or a related field.
• 3+ Years of experience.
• Disease management experience.
• Certified Case Manager or similar advanced credentialing or ability to obtain certification within 2 years of hire.
• We'd love it if you had experience with motivational interviewing.
• This role requires excellent communication skills and organization.
• Spanish-speaking candidates are preferred!
• We are unable to consider candidates outside of the United States, candidates in the state of California, or those in US Minor outlying islands and territories.