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
- 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 license in the State of Texas (bachelor’s degree)
- Must have two (2) years of Nursing experience, preferable home health and hospital experience
- Strong professional level of knowledge and comprehensive clinical assessment skills in the adult population and chronic disease management
- Problem solving skills and ability to multi-task
- Excellent organizational and time management skills
Summary
The Patient Care Navigator is an administrative position that works with the clinical team. The Patient Care Navigator facilitates delivery of information to individual members of the clinical team to help coordinate prescribed healthcare services. Patient Care Navigators are liaisons between beneficiaries/members and healthcare components. In addition, the Patient Care Navigators’ role is to help patients understand treatment plans. Through beneficiary/ member contact, Patient Care Navigators will assist in identifying care gaps in patient care by tracking ordered wellness visits, chronic care management and transition care services. Navigators will report to the Director of Clinical Operations. Patient Care Navigators will not recommend or render any medical services.
Essential Duties and Responsibilities
- Increases involvement of the beneficiary/member and or their caregiver in the decision-making process.
- Minimizes fragmentation of care within the healthcare delivery system.
- Assists in improving adherence to the plan of care for the beneficiary.
- Assists beneficiary/member by acting as an advocate.
- Collaborates with clinical teams to focus on moving the beneficiary/member to self-care (independence) whenever possible.
- Assists in coordinating care for beneficiary/member, including chronic care management and transition care management.
- Participates in team meetings and quality improvement initiative.
- Focuses on transitions of care, which includes a complete transfer from one care setting to the next that is safe, effective, and timely.
- Collaborates with outpatient staff to ensure that safe transition to the new care setting and follow up with the primary care physician and/or specialist.
- Improves outcomes by utilizing adherence guidelines, standardized tools, and proven processes to measure a beneficiary/member’s understanding and acceptance of the proposed plans, his/her willingness to change, and his/her support to maintain health behavior change.
- Facilitates health and disease beneficiary/member education.
- Coordinates with clinical teams with the goal of moving beneficiary to optimal levels of health and well-being.
- Improves beneficiary/member safety and satisfaction with their healthcare needs.
- Expands the interdisciplinary team to include beneficiary/member and or their identified support system, healthcare providers; including community based and facility-based professionals (i.e. pharmacists, Medical Social Workers, holistic care providers).
- Improves beneficiary/member experience by coordinating appointments and referrals with specialists using our Preferred Provider Network.
- Maintains a daily census of beneficiaries/members’ admissions, discharge dispositions.
- Demonstrates proficiency with electronic medical records and care coordination systems.
- Documents all interactions between beneficiary/member/ caregiver and all components of the healthcare delivery system.
- Adheres to all policies and procedures including but not limited to the HIPAA Privacy rule.
- Performs other duties as assigned.
Knowledge, Skills and Abilities
- Knowledge with Care Coordination of the elderly.
- Ability to work with a high attention to detail.
- Compassion and empathy.
- Strong communication and interpersonal skills; both written and oral.
- Proficiency with electronic healthcare records systems.
- Proficiency in Excel and Word.
- Minimum Education and Experience.
Education
- High School diploma
- Driver’s license
- Preferred One (1) year of outpatient or inpatient care setting experience
- Fully bilingual preferred (English/Spanish)
Genuine Health Group offers a competitive compensation and benefits package that includes a 401k matching program, fully subsidized medical plans, paid holidays and much more. Base salary will be commensurate to professional experience. All final employment offers are contingent upon successful completion of background checks.
Genuine Health Group is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Job Type: Full-time
Pay: $84,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Employee discount
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Referral program
- Vision insurance
Application Question(s):
- Will you now or in the future require sponsorship to work in the US?
- Please provide salary expectations for this position.
Experience:
- home health nursing: 2 years (Required)
- adult population and chronic disease management: 2 years (Required)
Language:
- English and Spanish (Preferred)
License/Certification:
- RN License in the State of Texas (Required)
- transportation method to travel within Harris County (Required)
Location:
- Harris County, TX (Preferred)
Willingness to travel:
Work Location: On the road
