Job Description

Job Description

Job Description

Salary: $21 - $29

Population Health Coach (bilingual in English & Spanish)

Keywords: Health Coach, motivational interviewing, brief interventions, patient panel management, patient education in chronic disease management 

Location: Winters, CA

Projected hire date: mid-Sep 2024

Hours: 40 Full-Time

We are excited to expand our team and are on the lookout for a bilingual (English/Spanish) Population Health Coach (PHC)! As a PHC with us, you will work as a member of our medical care teams, providing holistic patient panel management, health coaching, and act as an advisor for quality improvement.

As a PHC with Winters Healthcare, you will use clinical registries to identify care gaps and ensure continuity of care is being met for our patients, including preventative care standards. Alongside panel and population health management, you will be able to support patients by providing health education in a mutually collaborative way. In this role, you would be an extension to the provider, working with patients to establish a trusting relationship to gain understanding of the patient’s background and environment; providing brief interventions such as motivational interviewing, health education, education related to chronic disease management, and anticipatory guidance to engage patients to achieve their health goals.

The ideal candidate is well-rounded in the basics of primary care, health wellness, motivational interviewing, and goal setting. Experience with glucometer teaching, blood pressure monitoring, and insulin and diabetes education are preferred. The ideal candidate enjoys working with people, is compassionate, and building relationships; strong communication skills are a must, – listening included – and the ability to establish effective, trusting relationships, and passion to provide exceptional care is key. Can you see yourself here? We hope so!

Responsibilities:

• Communicate, collaborate and work in a team-oriented environment supporting relational care
• Provide holistic panel management for all individual care gaps of clinic population
• Use clinical registries to identify care gaps and ensure continuity of care for known standards and preventative measures
• Provide up-to-date health education to patients and families in a collaborative and patient-centered manner
• Work within a team-based model of care as part of the clinical care teams
• Use motivational interviewing techniques to increase patient and family engagement in care
• Skillfully provide appropriate patient-education related to chronic disease management as requested by primary care providers

Qualifications:

• Bilingual fluency in English/Spanish is required (ability to read, write, and speak)
• Bachelor’s degree in health or health-related field preferred (open to Associate of Science in related field)
• Experience in primary care, or 2+ years providing health education in a collaborative style is preferred
• Experience with glucometer teaching, blood pressure monitoring education, insulin & diabetes education

Hours:

• Operating Hours: Mon. Tues. and Thurs.: 8:00 am – 8:00pm; Wed. and Fri.: 8:00 am – 5:00pm.
• Working Hours: 40 hours per week, with one evening shift 11am to 8pm. 

Compensation and Benefits:

• Hourly rate range is $21 - $29, and is determined based on experience
• Covered insurances include medical, dental, vision, life insurance/ AD&D, all 100% sponsored for employee.
• Paid time off (PTO): paid Holidays off, floating holidays, PTO (~28 days in year 1)
• Continuing Education Unit (CEU) Reimbursement: Licensure, $300 CEU Funds, & 8 hours of CEU PTO
• 401K retirement match at 3%
• We provide three pairs of embroidered scrubs at hire, and $100 scrubs allowance each year after the first.
  

Read below for the full job description: 

Population Health Coach

Reports to : Medical Department Manager

FLSA Status: Non-Exempt, hourly

 

Summary of Duties :

The Population Health Coach (PHC) operates as a member of our medical care team, providing holistic patient panel management, health coaching, and advises on quality improvement. The PHC uses clinical registries to identify care gaps and ensures continuity of care is being met for our patients, including preventative care standards. Alongside panel and population health management, PHCs will support patients by providing health education in a mutually collaborative way. The PHCs are an extension to the provider, working with patients to establish a trusting relationship to gain understanding of the patient’s background and environment; providing brief interventions such as motivational interviewing, health education, education related to chronic disease management, and anticipatory guidance to engage patients to achieve their health goals.

Essential Functions

Under general supervision, the Integrated Health Coach’s primary responsibilities include but are not limited to:

• Provide holistic panel management (i.e., ensuring everyone assigned to clinic is up-to-date on basic preventative care such as cancer screenings or immunizations) for all individual care gaps (i.e., discrepancy between care received and recommended best practices) of clinic population
• Create best practices for ongoing panel management of care gaps for a clinic population considering patient preferences and feasibility
• Provide whole person panel management according to known standards of specific conditions and preventative measures considering patient preferences and feasibility of recommendations
• Use clinical registries to identify care gaps and ensure continuity of care for known standards and preventative measures
• Be accountable for team performance on all quality measures related to quality improvement program (QIP) from Partnership health plan
• Provide up to date health education to patients in a collaborative and patient centered manner
• Skillfully provide appropriate patient-education related to chronic disease management as requested by primary care providers
• Use motivational interviewing techniques to increase patient and family engagement in following through with care gaps and chronic disease education
• Work within a team-based model of care that includes MA’s, PCP’s, Front Office, and Behavioral Health
• Participate in improvement workgroups and initiative to develop best practices, clinical guidelines, to improve delivery of services, quality of care, health outcomes, and patient experience
• Communicate with team in a clear and efficient manner regarding assessments, interventions, and care plans
• Provide brief clinical services and interventions in a flexible manner
• Recognize when to make recommendations for care plan changes if patients are not improving;
• Establish collaborative relationships with support groups and other community resources that can serve as referral resources for patients
• Provide ongoing case management as necessary
• Participate in quality improvement projects as needed

Minimum Requirements:

Education and Work Experience

• Bachelor’s degree in health or health related field is preferred (open to Associate in Science Degree)
• Experience in primary care, or 2 or more years partnering with patients to understand their environment and background to provide health education and identify internal and external resources for optimal patient care
• CPR Certification (or receipt of certification within 60 days of hire)
• Experience with glucometer teaching, blood pressure monitoring education, insulin & diabetes education

 

Knowledge, Skills and Abilities:

• Fluency (the ability to read, write and speak) in English and Spanish is required
• Well-organized and detail-oriented with the ability to establish and maintain working relationships with patients, employees and the public
• Effective oral and written communication skills, and excellent interpersonal skills
• Emotional intelligence and critical thinking skills
• Ability and comfort building relationships with coworkers and patients of all ages
• Demonstrated team experience and proven successes in implementation of team goals
• Significant background providing outstanding customer service
• Proficient in computer programs such as Microsoft Office: Word, Excel, Outlook
• A passion and dedication for serving the healthcare needs of our clients

Other Requirements:

Authorization and consent for Winters Healthcare to investigate candidate’s background with a consumer report for employment purposes, to evaluate candidate/employee for employment, promotion, reassignment, or retention as an employee

Additional Desired Qualifications:

• Experience with Electronic Health Records (EHR) preferably Epic.
• Previous experience in a health center setting is highly desirable.
• Experience working with an integrated behavioral health team.

Location:

• Winters, California

Operating hours:

• Wednesday and Friday: 8:00 am - 5:00 pm; Monday, Tuesday and Thursday: 8:00 am - 8:00 pm

Hours:

• Operating Hours: Mon., Tues. and Thurs.: 8:00 am – 8:00pm; Wed. and Fri.: 8:00 am – 5:00pm.
• Working Hours: 40 hours per week, with one evening shift 11am to 8pm.

Expected Hire: 

• mid-September 2024

Compensation and Benefits:

• Hourly rate range is $21 - $29, and is determined based on experience
• Covered insurances include medical, dental, vision, life insurance/ AD&D, all 100% sponsored for employee.
• Paid time off (PTO): paid Holidays off, floating holidays, PTO (~28 days in year 1)
• Continuing Education Unit (CEU) Reimbursement: Licensure, $300 CEU Funds, & 8 hours of CEU PTO
• 401K retirement match at 3%
• We provide $300 scrubs allowance at hire, and $100 scrubs allowance each year after the first.

 

Physical Demands:
While performing the duties and tasks of this job, Employee is regularly required to stand; walk; work on irregular surfaces; reach with hands and arms; use hands to finger, handle or feel objects, tools, or controls; talk or hear; and taste or smell. Employee is occasionally required to sit and stoop, kneel, crouch, bend, squat, twist or crawl. This job requires physical effort and the ability to place or retrieve items at below waist level may be required.

Employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision and depth perception, and the ability to adjust focus. Employee occasionally may be required to transfer patients to and from a wheelchair. The physical demands described here are representative of those that must be met by Employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

Environmental/ Working Conditions:

The environment is a standard office environment. Regular office hours are Monday through Friday. Occasionally, evenings, weekends and overtime may be required. Office hours may be changed as business needs dictate. The working environment characteristics described here are representative of those an employee may encounter while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.

While performing the duties of this job, Employee is occasionally exposed to toxic or caustic chemicals, required to work near moving mechanical parts and sharp instruments, and may be at risk of electrical shock. The noise level in the work environment is usually moderate.

Job Tags

Hourly pay, Holiday work, Full time, Work experience placement, Flexible hours, Weekend work, Afternoon shift, Monday to Friday,

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