RN Health Coach

Collaborates with physicians, advanced practice providers, and ancillary health care team members to coordinate care. Operates from an in-depth understanding of the importance of total health management and supports the patient and family/caregiver choices. Manages a large population on our value based agreements through our ACO. Activities include - pre-visit readiness; coordination of care; gaps in care completion and performance improvement activities that continue to develop the team based health care concept.

Responsibilities:

* Prioritizes patient care needs, within established patient population and individually, to optimize long term health and health outcomes.

* Collaborates with providers and clinicians to utilize best practice, evidence based guidelines in order to develop systems for achieving optimal patient and family/caregiver outcomes.

* Demonstrates a range of interventions/skills including counseling, coaching, motivational interviewing, coordination, education, referral and advocacy to gain access to services and resources to empower patients, family and/or caregivers to involve them in mutual goal-setting, planning, behavior changes, and providing them the highest quality care.

* Delegates appropriate tasks to members of the health care team and follows up when necessary to assure the delegated task is completed.

* Demonstrates the ability to coach patients and improve their health behaviors. Apply a flexible and creative approach to problem solving.

What you will need:

• Bachelor's Degree in Nursing required (enrollment in BSN completion program will be considered). Master's Degree in Nursing preferred.
• Current State of WI or eNLC State RN License.
• BLS (CPR) Certification.
• Certification in Guided Care Nursing, Nursing Case Management and/or Gerontological Nursing preferred.
• At least 5 years of hospital-based nursing experience, adult primary care clinic, or home care experience.
• RN case management, team lead and/or other nursing leadership experience preferred.
• Basic understanding of computer use: Microsoft Office programs, internet, and health information technology (EHR).
• Experience with Epic EMR preferred.