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Disease Management Health Coach-Rn

Company

Presbyterian Healthcare Services

Address , Albuquerque, 87113
Employment type PART_TIME
Salary
Expires 2023-10-11
Posted at 9 months ago
Job Description
Overview:
Serves as a health coach for members identified as needing disease management services. Through telephonic interventions the health coach will assess the member s learning needs, readiness to change, and gaps in care related to the member s chronic condition. The health coach provides education, self-management tools, and information to assist the member in achieving behavioral lifestyle changes to reduce risk and improve health outcomes. The health coach works in collaboration with the primary care provider and care team to take action on gaps in care related Medicare Star and Centennial Care HEDIS performance

Type of Opportunity: Part Time (.45 to .89)
FTE: 0.500000
Exempt: Yes
Work Schedule: Days <
Qualifications:
New Mexico Registered Nursing License required. Three years of experience in nursing required. Ability to perform nursing assessments, conduct behavioral coaching and disease management education utilizing established tools and criteria. Ability to assess members for readiness to change behaviors. Ability to communicate telephonically and via interactive electronic communication with members and providers. Computer knowledge and skill to include Windows, word processing and database systems. Strong customer service skills. Computer literacy to include maintaining spreadsheets, charts, and tables of data and statistics in accordance with quality measures and utilization standards. Multi-cultural experience preferred. Bilingual preferred
Responsibilities:
  • Provides coaching and education to members related to disease specific self-management goals and behavioral lifestyle changes.
  • Provides ongoing communication to the member s primary care provider and care team regarding the member s self-management goals and progress towards goals,
  • Collaborates with member, caregivers, providers, and other healthcare team members to develop a comprehensive plan of care.
  • Performs other functions as required.
  • Educates member about health condition, symptoms, and how choices can impact health outcomes.
  • Utilizes the nursing process to provide direct patient care and health coaching for disease management using telephonic methods and interactive video visits.
  • Follows evidence-based care guidelines for disease-state management.
  • Identifies gaps in care related to the member s chronic condition and preventive screening needs related to age and gender. Places orders on behalf of the primary care provider using approved nursing protocols.
  • Uses advanced nursing assessment and critical thinking to assess the member s health care needs.
  • Attends and present cases at clinical meetings, as requested.
  • Abides by organizational policies and procedures as well as State and Federal regulatory requirements to include Medicaid, Medicare, and Commercial requirements.
  • Uses adult learning principles to facilitate behavior change and patient empowerment.
  • Works with member to establish a self-management goal(s) and develops education and coaching plan to support lifestyle modifications and to promote a healthy lifestyle.
  • Develops and maintains cooperative working relationships between Presbyterian Medical Group, Contracted Providers and Health Plan Departments related to disease management activities and initiatives.
  • Maintains clear and effective ongoing communication with primary care providers. Methods of communication include documentation in the electronic health record, Inbasket messaging, and oral communication to ensure continuity of care for the member.
  • Performs member outreach for special projects related to Medicare Star and Centennial Care HEDIS performance measures on behalf of the health plan.
  • Uses a holistic approach to identify and take action on social determinants of care to include referrals to members of the health care team and community resources.
  • Documents health coaching interventions in care management system.
  • Assesses members for readiness to make behavioral lifestyle changes.
  • Monitors member s response to interventions and adjusts plan of care when appropriate.
  • Successfully works within the constraints of the role by recognizing when a referral to a different level of care is indicated and initiates referral to Nurse Advice Line, Case Management, Care Coordination, Community Health Worker, or community resources, when appropriate.
  • Acts as a liaison between member, providers, and other members of health care team.
Benefits:
We offer more than the standard benefits!
Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!

Learn more about our employee benefits:

https://www.phs.org/careers/why-work-with-us/benefits

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.

Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.

About Presbyterian Healthcare Services
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

About Our Regional Delivery System
Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.

We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico
New Mexico continues to grow steadily in population and features a low cost-of living.

Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.

New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses. <