The Patient Health Coach will serve as an adjunct to the patient’s primary care provider to coordinate their maintenance healthcare needs designed to optimize health for a variety of chronic disease conditions such as diabetes, hypertension, hyperlipidemia, and others. The Patient Health Coach will initiate care for assigned patients under protocol and supervision of a physician that will include the scheduling of office visits, diagnostic tests, and ordering of prescription refills, as necessary to meet the criteria set forth for the management of their particular chronic condition as outlined by the NCQA Patient Centered Medical Home program and/or HEDIS measures.
- Assist in the development, implementation and maintenance of an appropriate supportive infrastructure for HMG’s Patient Centered Medical Home programs.
- Investigates patient charts for completeness and compliance with NCQA and HEDIS measures
- Enact care plans under physician guidance for patients to include scheduling of patient for services necessary to meet disease management guidelines
- Update patient medical records to reflect current condition, medications, etc… and remove outdated or lapsed conditions/medications
- Perform treatment plan review, coordination of care, and follow-up as needed
- Provide Provider communication and support as needed on all assigned cases
- Coordinate transitions between various areas of care
- Identify ways to add value to treatment plans and consult with providers and staff on those ideas
- Be a valued member of the team that will oversee the management of patients and the PCMH program as a whole
- Establish close relationships with patients that will increase compliance with treatment recommendations.
- Ensure an appropriate documentation and reporting system for patient results/concerns and provides recommendations for resolution or change as needed
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.
- Minimum High School diploma or equivalent required
- LPN or RN licensed by the state in which employed
- Ability to work independently under protocol in an accountable manner
- Empathetic and patient
- Excellent communication skills both written and oral
- Superb time-management, organizational and problem-solving skills
- Knowledge of NCQA and HEDIS quality measures related to chronic disease management
- Customer Focus
- Ethics and Values
- Interpersonal Savvy
- EMR and scheduling proficiency
- Problem Solving
Holston Medical Group - 2 years ago
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