Linkage to Care Coordinator

Overview

Job Summary

Engages patients/teammate and encourages them to take an active role in their health by providing them with the tools necessary to make healthy lifestyle choices and adopt life-long healthy behaviors. Help patients/teammate unlock personal motivation to make lasting changes and simultaneously serve as the patients/teammates primary conduit to the health care provider as they help coordinate necessary services both within and outside of the health system.

Essential Functions

• Collaborates with patients/teammates to actively engage a population of medically vulnerable or chronically ill patients/teammates in their care, assisting them through the process of actively working towards better health by providing support, encouragement, and education.
• Communicates with patients/teammates (and caregivers) in person, in groups, by telephone and via electronic means.
• Implements a range of skills including but not limited to coaching, motivational interviewing, behavior modification, goal setting, barrier assessment and problem solving.
• Advocates and facilitates referrals to gain access to services and resources for patients/teammates, including assistance programs, community based services and mental health support.
• Provides customized, evidence-based patient/teammate education in a variety of areas including but not limited to weight management/exercise, tobacco cessation, stress reduction and chronic disease self-management.
• Encourages the patient/teammate to participate in shared decision making with his/her doctor when faced with multiple treatment options. Helps the patient/teammate understand the options and evaluate personal preferences and values related to likely treatment outcomes, with the goal of preparing the patient/teammate to discuss the risks and benefits of each option with the physician.
• Communicates care plans and pertinent information with the primary care team as well as with other specialists or parties participating in the care of the patient/teammate.
• Assists with the coordination of care across the care continuum (including home care, outpatient care, ER care, and hospital care).

Physical Requirements

Work may occur in a variety of settings, including office, clinic, school, or other community setting. Requires walking, standing, sitting, lifting, reaching, bending, pushing and pulling. Must be able to lift and support the weight of 50 pounds in handling equipment and supplies. Must have intact sense of sight, hearing, smell, touch and finger dexterity. Must be able to move about the medical center and to travel to various clinical and community locations.

Education, Experience and Certifications

High School diploma or equivalent required. Bachelor's degree in health discipline preferred. Health Coach Certification required (or attained within first year of employment).