SCOPE OF ROLE  

The Health Coach coordinates and facilitates members’ individualized plan of care in collaboration with members, families, caregivers, and other health care providers. The Health Coach uses their clinical judgment to determine a member’s needs both in the home and throughout an acute care episode. The Health Coach provides support, guidance, education, and acts as a liaison between the member’s PCP and specialty physicians to maximize health outcomes and prevent unnecessary hospitalizations. This role also supports a variety of care programs, outreach, education, quality improvement, and other initiatives as needed. 

ROLE RESPONSIBILITIES 

The Special Needs Plan Health Coach job description is intended to point out major responsibilities within the role, but it is not limited to these items. 

• Conducts face-to-face visits with members in both healthcare facilities and in their homes and initiates telephone outreach  
• Facilitate “Intakes” and maintain required documentation in EMR web-based application including but not limited to the following: Surveys, Health Risk Assessment progress notes, and other documentation as required by Bright Health. ​ 
• Uses all components of the Eric Coleman Transitions of Care model and nursing process including assessment, triage, planning, implementing, and evaluating care to meet the members’ needs  
• Provides health maintenance, medication, and disease management education to members and families/caregivers  
• Coordinates appropriate member care appointments, community resources, referrals, management program benefits and special focus programs  
• Ensure member’s preventive care appointments are scheduled and encourage member to participate in those appointments. ​ 
• Maintains compliance with CMS mandated health risk assessments, care plans, and interdisciplinary care team meeting requirements.  
• Active participation in Interdisciplinary Care Team presentations  
• Coordinates continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the members’ primary healthcare provider(s) and medical directors  
• Takes an active role in coordinating and initiating member’s access to Bright Health programs and specialty benefits offered beyond traditional Medicare  
• Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships while effectively prioritizing patient care.  
• Works with outside facilities, agencies, and vendors on a routine basis, maintaining positive working relationships  
• Supports members and their families/caregivers, and provides compassionate care  
• Frequent travel is required for member visits, conferences, community events, health fairs, etc. 
• Make referrals / linkages to community resources on an individualized basis. ​ 

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE 

• Current Licensed Practical Nursing or Licensed Vocational Nurse certificate from an accredited Nursing Program  
• Two (2) or more years' experience as an LPN/LVN, preferably in a case management setting  
• Driver’s license, auto insurance, and safe driving history  
• One (1) year of healthcare related experience required 
• Awareness and experience with HIPAA requirements for healthcare communications preferred 
• Prior experience with URAC/NCQA accreditation preferred 
• Bi-Lingual preferred

PROFESSIONAL COMPETENCIES 

• Prioritizes and plans work activities; uses time efficiently and has the ability to multi-task. 
• Excellent communication skills, both oral and written 
• Approaches challenges calmly and objectively to identify the best solution 
• Capable communicator that can interact with others at multiple levels within the organization, customers and providers 
• Leads through influence and example 
• Strong operational mindset and uses data to draw insights 
• Thrives on driving results in a collaborative environment 

LICENSURES AND CERTIFICATIONS 

• Current Licensed Practical Nursing or Licensed Vocational Nurse certificate from an accredited Nursing Program; or equivalent combination of education and experience. 

WORK ENVIRONMENT 

The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Travel, up to 10% of the time may be required.