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Wellness Health Coach

Overview

Provides, education, client advocacy, regular evaluation and feedback about clients on caseload. Also evaluates clients’ eligibility for other social service programs. Alerts team members when follow-up is required and ensures efficient and successful access and linkage to the full array of community based services with the goal of client’s successful completion of the care plan. Works under close supervision.


Responsibilities
  • 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; notifiesy 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 initiaition 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.
  • Performs other duties and participates in special projects, as required.

For CMO:

  • Assists with general program supports in areas of technology such as CarePort, Interactive Voice Response (IVR) Remote Patient Montiring, Tiger Text. Assists in re-engaging clients who have missed or have not answered/returned calls to care management team. May  provide canvasing efforts to locate client.
  • Participates in initial and ongoing training to maintain basic level of knowledge related to Community Based Resouces and new Internal Programs.
  • Assists clients in obtaining MD appointment.

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 Groupson site at WeCare.
  • Facilitates periodic case record reviews and case conferences with all providers serving the client. Reviews new cases for completeness of documentation.

Qualifications

Education:  High School Diploma or equivalent required. Associate’s or Bachelor’s degree in a human services or related field preferred. 

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.


ABOUT US

The Visiting Nurse Service of New York (VNSNY) is one of the nation's largest not-for-profit home- and community-based health care organizations, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Counties. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost-effective health care in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, health plan members, and clients from before birth to the end of life. On any given day, VNSNY employees - including nurses, rehabilitation therapists, social workers, home health aides and other professionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to approximately 40,000 individuals in our care helping them to live the best lives possible in their homes and communities.