Job Description
Summary RN Health Coach is a purposeful, result oriented structured client interaction that is provided by an RN for the purpose of promoting achievement of client goals. RN Health Coach promote and facilitate growth, healing and wellbeing of the whole person using coaching principles and healing modalities that integrate body-mind-emotion-spirit- environment. Health Coaching is a skillful use of evidence based, conversations, clinical interventions and strategies to safely engage clients who have Chronic conditions or at moderate to high risk for developing them. RN Health Coach focuses on disease process management and education intended to reduce unnecessary hospital admissions through the patient's understanding of their condition as well as working closely with the patients' primary care physician to detect an exacerbation with sufficient time to avoid an ER visit.
Essential Duties and Responsibilities - Completes RN Health Coach Evaluation which includes a systematic assessment of patient's functional, psychosocial needs, fall precautions, safety, environmental, nutritional, Medication reconciliation, Cognitive, and medical history, and Point of Care testing
- Identifying client readiness to change
- Identifying opportunities and issues related to the client's growth
- With input from patient/care giver establish centered goals and outcomes to formulate and implement plan of care
- Evaluate effectiveness of Care Plan and make necessary adjustments
- Plan and structure the coaching interactions
- Prepares RN Health Coach and progress notes, and coordination of services on a timely basis
- Coordinate PCP follow ups (call to help ensure they made their appointments) or set an appointment from the patient's home
- Communicate directly with PCP and/or specialists regarding any problems, or changes in therapy and/or medications
- Provides for the emotional and physical comfort and safety of clients, taking into consideration their rights and cultural backgrounds
- Providing patient education, monitoring of health needs, and coordinating of community resources
- Notify physician and supervisor of unusual reactions and/or changes in client's condition
- Participate in case conferences, team meetings, staff meetings and Performance Improvement activities as assigned
- Facilitating patient empowerment and quality of life by promoting educated, independent patient choice on all aspects of care
- Identifying opportunities for health promotion and illness prevention
- Helping clients achieve wellness and autonomy
- Improving beneficiary safety and satisfaction
- Show compassion and empathy and take a genuine interest in the patient and his/her well-being
- Adhere to all policies and procedures including but not limited to the HIPAA Privacy rule
- Documentation on EMR proficient and timely manner
- Prepares clients' discharge by reviewing and amplifying discharge plans; coordinating discharge and post-discharge requirements; orienting and training family members on post discharge care including providing available information on resources available to the patient
- Ensure that all coaching interactions are respectful and non-judgmental
- Participation in Genuine at Home sponsored in-service training
- Adheres to all policies and procedures including HIPAA
- Maintains professional licensure and other requirements
- Performs other duties as assigned
Knowledge, Skills and Abilities - Documentation Skills
- EMR proficiency
- Analyzing Information
- Critical Thinking Skills
- Decision Making
- Research Skills
- Verbal and written communication proficiency
- People Skills
- Conflict resolution
- People Management
- Integrity, compassion
- Bilingual: Spanish and English
Minimum Education and Experience - Current Registered Nurse (RN) license in the State of Florida; Bachelor's required
- 2+ years of nursing experience in case management, disease management, home or facility settings
- Experience managing adult, Medicare/Medicaid, and medically complex or high-risk patient populations
- Strong clinical assessment skills with a focus on chronic condition management and care planning
- Experience in care coordination and transitions of care, including post-discharge follow-up and readmission prevention
- Experience with patient education, health coaching, and holistic care to drive engagement and self-management
- Experience working collaboratively with interdisciplinary teams, including PCPs and specialists
- Proficient in MS Office Suite to include Word, Excel, Notes, Outlook
Job Location
- Hybrid Remote/Field role
- Local travel required throughout Miami Dade - West Broward
Note: Nothing in this job specification restricts management's right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described under various headings above. They may be subject to change at any time due to reasonable accommodation or other reasons. The above statements are strictly intended to describe the general nature and level of the work being performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required of employees in this position.
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