The Health Coach position exists to: Address social determinants of health and promote patient self-management skills through the provision of community resource referrals, education, motivational interviewing, goal setting, and follow-up with patients. Apply Here (Requisition Number: HEALT02535)

Target Population:

  • Patients with health education gaps
  • Patients on one chronic disease registry
  • Prenatal patients

Knowledge, Skills and Abilities:

  • Proficient verbal and written communication skills in English and Spanish required
  • Excellent organizational skills
  • Ability to flourish in an unpredictable daily flow environment
  • Ability to function effectively within a team-based care system
  • Sensitivity to low income, ethnic minority community
  • Ability to provide health education and support in both an individual and group setting
  • Strong critical thinking and problem-solving skills
  • Self-motivated with a demonstrated ability to take initiative

Essential Duties and Responsibilities:

  • Outreach and schedule Covid-19 vaccinations using motivational interviewing to address vaccine hesitancy and questions.
  • Provide Planned Care on the pod as per registry workflows for the following populations:
  • Newborn visits
  • Weight loss counseling
  • Basic nutrition counseling
  • Well Child Checks (1 year always and per provider requests)
  • Diabetes education and goal setting for patients with diabetes
  • Hypertension/Cholesterol
  • Tobacco cessation
  • Stress management and relaxation techniques
  • Deliver basic, diagnosis-specific health education for Planned Care populations of focus
  • Support interdisciplinary care team needs on the pod
  • Facilitate chronic disease self-management, goal setting and follow-up with all Planned Care patients:
  • Promote patient engagement
  • Apply Motivational Interviewing techniques to encourage behavior change
  • Provide resource coordination:
  • Provides referral information to community resources as per resource cards
  • Coordinate care with internal and external community partners
  • Support higher level care coordination activities as directed by the Care Team
  • Facilitate patient Group Visits:
  • Prepare group education, survey and activity materials
  • Set up and teardown of group visit space
  • Facilitate group discussions
  • Provide health education based on group needs
  • Deliver Anticipatory Guidance as defined by protocol
  • Administer Prenatal Plus Program for eligible patients:
  • Identify all Obstetrics patients on Medicaid and screen for program eligibility
  • Complete comprehensive intake on all eligible patients
  • Provide continuity of care throughout pregnancy in collaboration with Behavioral Health Provider, Registered Dietician, and Primary Care Provider
  • Ensure all Prenatal Plus patients see a Health Coach or Behavioral Health Provider at each visit as appropriate
  • Document program and patient data correctly and completely per protocol
  • Offer brief behavioral health interventions for lower-acuity patients
  • As directed by the Behavioral Health Provider /Primary Care Provider, provide education about exercise, stress reduction, sleep hygiene and setting self-management goals for patients on depression registry
  • Facilitate transfer of higher-acuity patients to Behavioral Health Provider
  • Additional duties as assigned

Due to Covid-19 pandemic, specific responsibilities of the position are variable. This position will initially focus outreach and scheduling Covid-19 vaccinations using motivational interviewing to address vaccine hesitancy.

Education / Experience Requirements:

1. BA/BS degree in Health/Human Services field preferred or equivalent experience

2. Experience providing health education/coaching required

3. Health Coaching Certificate Preferred

4. Experience working in a community health setting or with underserved populations preferred