Health Coach & Care Navigator

One Brooklyn Health System Inc.; New York (NY); Sur place; USD 40 000 - 65 000; Plein temps

Résumé du poste

One Brooklyn Health System Inc. is seeking a Health Coach to join our team, reporting to the administrative director and collaborating with licensed Registered Nurse staff to support Health Home At-Risk and Health Home eligibility initiatives.

The role emphasizes assessment, care planning, patient education, and population health management, including coordinating care for caseload patients and facilitating post-discharge transitions.

Qualifications

• MA/LPN/PCT or other clinical support staff member.
• Training or knowledge of vital signs, the use of standardized assessments of basic medical and substance use history and symptoms, and Motivational Interviewing, including goal setting.
• Experience with public speaking and interviewing.

Responsabilités

• Uses registries to identify patients with newly diagnosed, undiagnosed or poorly controlled chronic conditions and schedules follow-up appointments.
• Conducts outreach to patients with overdue screenings or upcoming appointments.
• Performs intake and assessment of patients with newly diagnosed or poorly controlled chronic conditions, screens for Health Home eligibility, and checks Health Home enrollment.
• Screens for behavioral health and substance use problems, including depression (PHQ), alcohol abuse (AUDIT), substance abuse (DAST) and smoking status.
• Reinforces education provided by PCP or nurse on management of the chronic disease, provides self-management tools, and reviews how to use those tools.
• Establishes goals and creates a care plan with the patient.
• Lead and participate in Diabetes Prevention and self management workshops
• Organize and participate in community events and fairs
• Works with patient to mitigate impacts of social factors on health and functional status, e.g. by arranging transportation for patients.
• Conducts post-visit review of next steps with patient.
• Coordinates care, assists with referral management, and conducts between-visit monitoring & outreach.
• Tracks and follows up on test results to ensure patient and caregiver take appropriate next steps as needed.
• Serves as primary care practice's first point of contact during post-discharge care transition from hospital or emergency department.
• Works with practice's performance improvement team.
• Assists in scheduling huddles and other internal team meetings.
• All other duties as requested.

Connaissances

MA / LPN / PCT

Public speaking

Motivational Interviewing

Goal setting

Interviewing

Formation

High School Diploma or GED

Description du poste

One Brooklyn Health System Inc. is seeking a Health Coach to join our team, reporting to the administrative director and collaborating with licensed Registered Nurse staff to support Health Home At-Risk and Health Home eligibility initiatives.

The role emphasizes assessment, care planning, patient education, and population health management, including coordinating care for caseload patients and facilitating post-discharge transitions.