Health & Wellness Coach

Summary

The Health and Wellness Coach provides administrative support to psychosocial services staff and case management services to patients. The Health and Wellness Coach position reports to the Psychosocial Services Manager or another designee.

This position is represented by SEIU-UHW. Salaries and benefits are set by a collective bargaining agreement (CBA), and an employee in this position must remain a member in good standing of SEIU-UHW, as defined in the CBA.

Job Duties

Care Coordination

• Primary Care coordination
• Tracks patients’ progress and alerts providers the need for enhanced services according to clinic prioritization
• Provides short term case management services
• Assists with patient specific barrier removal
• Eligibility determination to ensure access to community services
• Troubleshooting around medications, transportation, benefits
• Available to provide community accompaniment for vulnerable patients in collaboration with care team
• Tracks, manages, and facilitates specialty referrals to ensure patients successfully follow-up
• Makes appointments and completes reminder calls for primary care provider panel
• Assists with medication reconciliation
• Integration of care (Medical and Psychosocial)
• Accepts warm hand offs of patients between Medical and Behavioral Health providers to facilitate integration of care.
• Helps coordinates behavioral health referrals and collaborates with patient’s community behavior health providers
• Maintains active list of relevant community resources and places appropriate referrals
• Familiar with basic local housing and shelter resources for provision to patients

Health coaching (patient self-management support)

• Coaches patients in self-management (e.g. medication adherence, lifestyle)
• Assists patients in developing and executing health-related action plans or behavior changes based on client goals
• Navigates problem-solving with patients as they encounter obstacles to achieving health-related goals
• Conducts brief interventions with patients regarding alcohol and tobacco use and other behavioral health issues as appropriate.

Panel Management

• Maintains accurate provider panel in Electronic Health Record with active patient definition
• Maintains chronic disease registries and targets patients for chronic care management activities at regular intervals such as
• Retention in care
• Chronic disease related education referrals
• Chronic disease related preventative tasks (use of standing orders)

Other Duties

• Actively participates in team meetings with internal staff and external partners
• Contributes to clinic quality improvement planning and implementation
• Responsible for data collection, entry and generation of reports
• Coordinates operation of special projects as assigned by supervisors