Care Management Coach - Cardiac Rehab

Aviary

3d•Remote

About The Position

Aviary Health was founded in 2020 by seasoned digital health entrepreneurs. In past roles, we've founded and scaled high-growth startups, run large health systems, advised government programs, built technology you use every day, and provided healthcare for millions of lives. Our mission is to empower everyone to live a long, full, and optimal life. We do this by working with patients to design a recovery program to meet their needs and ensure maximum benefits to their health. The Care Coach conducts regular patient outreach, monitors symptoms and clinical status, provides education on Heart Failure self-management, identifies barriers to care, and facilitates timely escalation of clinical concerns when appropriate. Through ongoing coaching, support, and education, the Care Coach helps patients build the knowledge, confidence, and healthy behaviors necessary to successfully prepare for and transition into Aviary Health's Virtual Cardiac Rehabilitation Program. This role plays a critical part in improving patient outcomes, reducing avoidable hospitalizations, and ensuring patients are engaged, informed, and clinically prepared throughout their Heart Failure journey.

Requirements

Bachelor's degree in Nursing, Exercise Science, or a related healthcare field.
Licensed Practical Nurse (LPN), Certified Exercise Physiologist preferred.
Current CPR certification.
Minimum of 2 years of experience in chronic care management or a related healthcare setting.
Experience working with patients with cardiovascular disease and heart failure is preferred.
Experience working with older patient population
Strong knowledge of cardiovascular disease and heart failure management.
Excellent communication and interpersonal skills.
Ability to work independently and as part of a healthcare team.
Proficiency in using electronic health records and other healthcare technology.

Nice To Haves

Licensed Practical Nurse (LPN), Certified Exercise Physiologist preferred.
Experience working with patients with cardiovascular disease and heart failure is preferred.
Experience working with older patient population

Responsibilities

Conduct telephonic and virtual care management for patients with heart failure.
Review and assess patients' medical, functional, and psychosocial needs remotely.
Reinforce heart failure self-management education.
Coordinate care transitions between healthcare providers and settings.
Manage an agreed-upon roster of patients each week, ensuring care management activities are completed in a timely manner.
Collaborate with providers, specialists, and care teams to optimize patient care.
Schedule and manage follow-up appointments
Assist in supporting care transitions and reducing hospital readmissions.
Educate patients and families about heart failure management and available resources.
Support patients in self-management and behavior modification interventions.
Conduct motivational interviewing to encourage lifestyle changes.
Maintain accurate and timely documentation in electronic health records (EHR).
Ensure services are provided in accordance with Care Management program requirements and protocols.
Adhere to applicable confidentiality, privacy, and data security requirements.