Health Coach/Licensed Practical Nurse - Edinboro Medical Center - FT

As a member of the health care team, assists with population health management through patient outreach and coordination of care, participates in the clinical visit to assist the provider, and provides self-management support to patients. Demonstrates leadership by communicating effectively, developing others, building and maintaining relationships, and guiding effective teams and work groups. Also mentors others within the team with office functions to support patient care and office operations. Follows all established protocols, policies, procedures and standardized work flows. Leads in managing data so that patients are effectively treated.

Actively participates in population health outreach through identification of patients with gaps in care through use of analytic tools and patient registries. Contacts patients and facilitates closing gaps in care.

Ensures pre-visit planning is completed by performing chart and data reviews in advance of patient visit and preparing for patient arrival by identifying items that need addressed during visit.

Demonstrates expanded rooming protocol by assisting the provider in addressing care gaps with the patient and appropriately activating standing orders.

Accurately performs clinical transcription during the patient encounter by documenting elements of the clinical visit under direct supervision of the provider and assisting with computerized provider order entry under direct supervision of the provider.

Uses a motivational interviewing approach to coach patients toward self-management, self-efficacy, and activation. Engages the patients to assess current state, collaboratively set goals, and review the after-visit summary. Instructs the patient on condition management, behavioral support, and addresses emotional demands of having a chronic condition. Reinforces the clinical care plan and follows up for ongoing activation.

Performs registry and quality data review and conducts population outreach to close gaps in care.

Oversees the identification of high risk patients and facilitates complex care management referrals. Works collaboratively with care team nurses to provide care coordination to rising risk patients.

Reviews and assesses with care team members to achieve population health management goals, to improve patient access to care and to reduce avoidable emergency department visits.

Cleans and sterilizes instruments per established standards. Ensures adequate inventory of medical supplies. Ensures all patient treatment areas are stocked with appropriate supplies using established inventory standards.

Performs in-house testing following established standards and policies.

Performs other duties as assigned or required.