Disease Management Health Coach-RN

Presbyterian Healthcare Services

4d

About The Position

Build your Career. Make a Difference. Presbyterian is hiring a skilled Disease Management Health Coach-RN to join our team. How you grow, learn and thrive matters here. • Educational and career development options, including tuition and certification reimbursement, scholarship opportunities • Staff Safety (a wearable badge that allows nurses to quickly and discreetly call for help when safety is a concern) • Differentials for night/weekend shifts, higher education, certifications and various lead roles (for eligible positions) • Malpractice liability insurance • Loan forgiveness through the New Mexico Higher Education Department • EPIC electronic charting system

Requirements

• Associates Degree
• New Mexico Registered Nursing License required.
• Three years of experience in nursing required.
• Ability to perform nursing assessments, conduct behavioral coaching and disease management education utilizing established tools and criteria.
• Ability to assess members for readiness to change behaviors.
• Ability to communicate telephonically and via interactive electronic communication with members and providers.
• Computer knowledge and skill to include Windows, word processing and database systems.
• Strong customer service skills.
• Computer literacy to include maintaining spreadsheets, charts, and tables of data and statistics in accordance with quality measures and utilization standards.

Responsibilities

• Serves as a health coach for members identified as needing disease management services.
• Through telephonic interventions the health coach will assess the member s learning needs, readiness to change, and gaps in care related to the member s chronic condition.
• The health coach provides education, self-management tools, and information to assist the member in achieving behavioral lifestyle changes to reduce risk and improve health outcomes.
• The health coach works in collaboration with the primary care provider and care team to take action on gaps in care related Medicare Star and Medicaid HEDIS performance
• Utilizes the nursing process to provide direct patient care and health coaching for disease management using telephonic methods and interactive video visits.
• Assesses members for readiness to make behavioral lifestyle changes.
• Uses adult learning principles to facilitate behavior change and patient empowerment.
• Follows evidence-based care guidelines for disease-state management.
• Uses advanced nursing assessment and critical thinking to assess the member s health care needs.
• Provides coaching and education to members related to disease specific self-management goals and behavioral lifestyle changes.
• Educates member about health condition, symptoms, and how choices can impact health outcomes.
• Uses a holistic approach to identify and take action on social determinants of care to include referrals to members of the health care team and community resources.
• Successfully works within the constraints of the role by recognizing when a referral to a different level of care is indicated and initiates referral to Nurse Advice Line, Case Management, Care Coordination, Community Health Worker, or community resources, when appropriate.
• Works with member to establish a self-management goal(s) and develops education and coaching plan to support lifestyle modifications and to promote a healthy lifestyle.
• Documents health coaching interventions in care management system.
• Provides ongoing communication to the member s primary care provider and care team regarding the member s self-management goals and progress towards goals,
• Identifies gaps in care related to the member s chronic condition and preventive screening needs related to age and gender.
• Places orders on behalf of the primary care provider using approved nursing protocols.
• Collaborates with member, caregivers, providers, and other healthcare team members to develop a comprehensive plan of care.

Benefits

• Educational and career development options, including tuition and certification reimbursement, scholarship opportunities
• Staff Safety (a wearable badge that allows nurses to quickly and discreetly call for help when safety is a concern)
• Differentials for night/weekend shifts, higher education, certifications and various lead roles (for eligible positions)
• Malpractice liability insurance
• Loan forgiveness through the New Mexico Higher Education Department
• EPIC electronic charting system
• Access to a fun, engaging and unique wellness program, including free on-site and community-based gyms, nutrition coaching and classes, mindfulness and meditation resources, wellness challenges and more.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree