- Develops personalized treatment plans using provider care plans and member preferences using a coach approach and the pillars of Lifestyle Medicine
- Supports a proactive, multidisciplinary team approach directed toward prevention, education and health promotion
- Establishes supportive relationship with members
- Assesses member's educational/clinical/social needs, prioritizing care based on elicited information from the member, Epic, and data analysis
- Acts as resource for members
- Documents touchpoints and progress into the electronic medical record
- Collaborates with the full scope of clinical team members to arrange for further medical treatment when needed
- Provides support and tools needed to help members take control of their health
- Delivers exceptional member experiences and engaging members in their healthcare journeys
- Improves health outcomes and better management of any chronic condition
- Lowers healthcare costs while improving outcomes
- Consults with other members of the healthcare team to solve problems and seek advice
- Works closely with client's vendors as appropriate to support member's needs where appropriate
- Identifies emergency situations and provides care within legal scope of practice
- Maintains member privacy and confidential member information
- Participates in outreach/follow-up phone calls and follow-up member visits
- Provides condition specific self-care education to client employee enrolled in the various condition management programs
- Serves as member advocate
- Acts as facilitator of Care Team meetings.
- For clients with CC+, proactive outreach to high-risk members identified through claims data
- Coaches effectively virtually using video and phone
- Collaborates with health center staff to coordinate and promote health and wellness programs
- May require other duties as assigned.
- Currently licensed Registered Nurse in state of practice
- Current certification AHA or ARC Basic Life Support for health care providers
- Current Wellness Coach Certification from Wellcoaches OR equivalent International Coach Federation-accredited program certification (must be obtained within 24 months of hire)
- Bachelor's degree (BSN) from four-year college or university (preferred)
- At least three years' experience as a Registered Nurse caring for members with any of the following conditions: Type 2 diabetes, asthma, heart disease, heart failure or hypertension.
- Experience in Condition Management, Certificate in Case Management, Care Coordination, Certified Diabetes Educator (CDE) Certified Diabetes Care and Education Specialist (CDCES) a plus
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