Wellness Health Coach

• Uses rosters and meets with the team members to identify clients that require follow up and assistance.
• Reviews care plan with the client and care management team; notifies and assists the care management team of any immediate needs and risk factors and makes referrals to services to address such needs.
• Utilizes motivational interviewing techniques and skills to address medical and psycho-social health. Motivates and supports client to participate in their individualized care plan.
• Provides outreach via phone and in person community visits to clients to follow up on self-care, medication fills/refills, care plan engagement/adherence scheduled visits, and test results received from providers.
• Reinforces education provided by client's medical providers related to the management of the chronic disease or conditions specified in their care plan; helps educate clients about conditions and self care/condition management.
• Provides health coaching and support for a caseload of assigned clients from initiation into program to completion. Works closely with the care management and team to discuss clients' progress in plan and goals for completion. Prepares detailed, accurate and timely case notes and utilizes care management platform as required to note client progress and updates.
• Provides information and assistance through advocacy and education to client/family on availability and eligibility of entitlements and community based services. Assists with client navigation of health system. Arranges transportation and accompanies clients to facilities/agencies, as necessary.
• Works collaboratively with team members to provide outreach for and engage resistant/hard to reach clients with overdue screenings or upcoming appointments and /or who have been non-compliant with necessary treatment appointments.
• For Wellness Program:
• Uses motivational interviewing techniques and skills to identify substance use history and symptoms related to care plan.
• Provides escorts to visits in the community in an effort to increase participation in an adherence to Wellness Plan and related appointments.
• Provides self-management tools and reviews how to use those tools. Conducts voluntary Wellness Groups on site at WeCare. Facilitates periodic case record reviews and case conferences with all providers serving the client. Reviews new cases for completeness of documentation.
• Participates in special projects and performs other duties as assigned.

Education:

• High School Diploma or equivalent required
• Associate's Degree or Bachelor's degree in a human services or related field preferred

Work Experience:

• Minimum of one year experience in care management, community health, social service, or medical practice preferred
• Effective oral/written/interpersonal communication skills required
• Basic computer skills required
• Bilingual skills may be required as determined by operational needs.