VAAA Cares Health Coach-Transitional Care Support Program

Virginia Applicants Only: Remote Work From Home/Hybrid may be required to visit clients and/or attend on-site training.

The Transitional Care Support Health Coach (HC) is key to ensuring safe and effective transfers in the movement of patients across the care continuum, serving as the bridge between the professional staff in a care setting (e.g. hospital) and the patient and/or family. All Health Coaches provide information and guidance to the patient and/or family for an effective care transition to improve self-management skills and enhance patient-practitioner communication. The HC assists patients with the ability to effectively communicate a personal health record, practice medication management, schedule follow-up appointments with their physician/specialist, and learn to recognize symptoms that indicate their condition is worsening and how to appropriately respond.

Position Responsibilities

• HC may conduct telephonic hospital inquiries with Care Managers, Utilization Managers, Floor Nurses, etc. and provide information and guidance to the admitted patient and/or family for acceptance of the transitional care support program for members identified and referred by the Managed Care Organization (MCO).
• HC will conduct telephonic home visits and follow-up phone calls, to maintain accurate and timely documentation on each referred patient in database system(s) including complete and concise activity entry notes within the guidelines of the Transitional Care Support Program. HC will conduct initial assessments to understand clients' health history and assist with developing personalized health goals and wellness plans.
• HC will serve as a guide coaching the patient in addressing critical issues and self-management tasks.
• HC provides information and guidance to improve patient practitioner communication.
• HC may collaborate daily with physicians and in-patient clinical staff on behalf of members.
• Coordinate care with numerous healthcare providers and identify community resources as needed tailored to care plan needs and personal goals as identified during initial assessment.
• Evaluate aspects of each patients condition, diagnoses, medications and support systems to develop an individualized plan which will lead to a successful outcome in: medication self-management, appropriate primary care, and specialist follow-up and knowledge of red flags.

Essential Skills and Experience

• Rely on extensive experience and judgment to plan and accomplish goals. Performs a wide variety of tasks
• Working knowledge of health care industry, caregiving, chronic disease management (a plus)
• Knowledge and appreciation of cultural diversity and low literacy issues in care provision
• Decision making handles all daily responsibilities relative to coaching a patient.
• Excellent verbal, written and computer literacy a must
• Ability to work methodically and patiently with limited resource and support
• Ability and willingness to self-motivate, prioritize, and be willing to change processes to improve effectiveness/efficiency. Adapts to changing patient or organizational priorities
• Ability to work independently, while collaborating with other team members
• Ability to work with patients/families of all ages and in a variety of settings

• Bachelors degree or equivalent experience preferably in Health Care Field, Care Coordination or at least 3 years of experience in healthcare. Familiar with a wide variant of community resources.
• Home based, telephonic position. Home based internet service preferred. Must have reliable transportation and a valid drivers license and able to attend in-person training when required.
• Ability to use phone systems and a computer with internet-based software and Microsoft Office/Excel.

Physical Demands and Work Environment

• This position is a remote, work from home or hybrid position with some physical requirements (ability to lift 20 lbs., walking, and climbing stairs).
• Corporate office located in Urbanna, Virginia. On-site work may also be required for training, etc.

• FLSA status: This is an exempt position.

  Disclaimer: This job description is not designed to cover or contain a comprehensive listing of all activities, duties or responsibilities that are required of the employee. From time to time, the supervisor will ask the job holder to perform additional duties related to the completion of the work. Other duties may be assigned from other programs as needed.

Bay Aging is an Equal Opportunity Employer. All applicants will be considered for employment without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, veteran or disability status. Bay Aging is committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. To request reasonable accommodation, contact MaDena DuChemin, Human Resource Manager at (804) 758-2396, Ext. 1228 or mduchemin@bayaging.org.