Collaborates with patients/teammates to actively engage a population of medically vulnerable or chronically ill patients/teammates in their care, assisting them through the process of actively working towards better health by providing support, encouragement, and education. Communicates with patients/teammates (and caregivers) in person, in groups, by telephone and via electronic means. Implements a range of skills including but not limited to coaching, motivational interviewing, behavior modification, goal setting, barrier assessment and problem solving. Advocates and facilitates referrals to gain access to services and resources for patients/teammates, including assistance programs, community-based services, and mental health support. Provides customized, evidence-based patient/teammate education in a variety of areas including but not limited to weight management/exercise, tobacco cessation, stress reduction and chronic disease self-management. Encourages the patient/teammate to participate in shared decision making with his/her doctor when faced with multiple treatment options. Helps the patient/teammate understand the options and evaluate personal preferences and values related to likely treatment outcomes, with the goal of preparing the patient/teammate to discuss the risks and benefits of each option with the physician. Communicates care plans and pertinent information with the primary care team as well as with other specialists or parties participating in the care of the patient/teammate. Assists with the coordination of care across the care continuum (including home care, outpatient care, ER care, and hospital care).
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
Number of Employees
11-50 employees