Health Coach - (CMA or LPN) - CIN - Erie PA/Warren PA- Hybrid

Job Title

New Opportunity! This position offers an exciting opportunity to work closely with AHN and independent primary care practice teams participating in AHN's Clinically Integrated Network (CIN) to enhance the quality and value of care delivered to Medicare beneficiaries. You will collaborate with practices to engage patients who may benefit from proactive outreach to help them address their preventive and chronic health care needs, coordinate their care, and meet their health goals. This is a hybrid role that involves both on-site and remote work. Travel is required between both Erie PA and Warren PA.

General Overview:

As a member of the health care team, assists with population health management through patient outreach and coordination of care, participates in the clinical visit to assist the provider, and provides self-management support to patients. Demonstrates leadership by communicating effectively, developing others, building and maintaining relationships, and guiding effective teams and work groups. Also mentors others within the team with office functions to support patient care and office operations. Follows all established protocols, policies, procedures and standardized work flows. Leads in managing data so that patients are effectively treated.

Essential Responsibilities:

1. Actively participates in population health outreach through identification of patients with gaps in care through use of analytic tools and patient registries. Contacts patients and facilitates closing gaps in care.
2. Ensures pre-visit planning is completed by performing chart and data reviews in advance of patient visit and preparing for patient arrival by identifying items that need addressed during visit.
3. Demonstrates expanded rooming protocol by assisting the provider in addressing care gaps with the patient and appropriately activating standing orders.
4. Accurately performs clinical transcription during the patient encounter by documenting elements of the clinical visit under direct supervision of the provider and assisting with computerized provider order entry under direct supervision of the provider.
5. Uses a motivational interviewing approach to coach patients toward self-management, self-efficacy, and activation. Engages the patients to assess current state, collaboratively set goals, and review the after-visit summary. Instructs the patient on condition management, behavioral support, and addresses emotional demands of having a chronic condition. Reinforces the clinical care plan and follows up for ongoing activation.
6. Performs registry and quality data review and conducts population outreach to close gaps in care.
7. Oversees the identification of high risk patients and facilitates complex care management referrals. Works collaboratively with care team nurses to provide care coordination to rising risk patients.
8. Reviews and assesses with care team members to achieve population health management goals, to improve patient access to care and to reduce avoidable emergency department visits.
9. Cleans and sterilizes instruments per established standards. Ensures adequate inventory of medical supplies. Ensures all patient treatment areas are stocked with appropriate supplies using established inventory standards.
10. Performs in-house testing following established standards and policies.
11. Performs other duties as assigned or required.

Qualifications:

• Minimum: High School / GED or Completion of a Medical Assistant Program or LPN License. Current State of PA LPN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) OR Medical Assistant Certification. 2 years of Medical Assistant experience.
• Preferred: High school diploma or equivalent.

Additional Employment Requirements:

• CPR certification.
• Act 34 Criminal Background Clearance Certificate
• Act 33 Child Abuse Clearance Certificate
• Act 73 FBI Fingerprinting Criminal Background Clearance Certificate