Department: 10170 Population Health - WI Health Coaches Status: Full time Benefits Eligible: Yes Hours Per Week: 40 Schedule Details/Additional Information: M-F 8-1630 no weekends/holidays at this time Major Responsibilities: Facilitates communications among patient/family, multidisciplinary team, medical management team, community resources and other disciplines to anticipate, identify, evaluate, and act to resolve any potential barriers and constraints to delivery of care in a timely manner. Understands and interprets multiple contracts and contractual obligations in order to enable the care management team to achieve maximum clinical and financial outcomes. Collaborates with the patient/family and inter-professional team including the primary care team, hospital care team, post acute care managers, and other care partners to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. May work embedded within a provider office or telephonically working with a care team. Uses evidenced-based approaches to increase patient and family activation and engagement in their own care. As appropriate to the population, partners with patient and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals. Assists in the development, procurement, and adoption of patient self-management educational resources. Identifies potential barriers to learning and/or to the optimal delivery of care. Reports abnormal findings to the responsible provider/care team, and collaborates to develop a plan. Independently manages CM caseload according to department expectations. Ensures timely completion of tasks and documentation related to MCO, regulatory and contractual requirements. Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care. Anticipates the needs of the patient, recognizes and responds to changes in a patient’s status and determines priorities of patient care based on essential patient needs. Coordinates patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) and other members of ACM to ensure smooth transitions of care. Coordinates referrals to other internal AAH departments and/or external community resources as necessary. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards. Licensure, Registration, and/or Certification Required: WISCONSIN - Registered Nurse license issued by the state in which the team member practices. Education Required: Bachelor's Degree in Nursing Experience Required: Requires 5 years of experience in clinical nursing or strongly preferred 1-2 years of care management experience. Knowledge, Skills & Abilities Required: Applicable certification is encouraged. Must be self-directed with the ability to work well independently and within a team environment while recognizing and meeting the individual needs of external and internal partners/customers. Ability to demonstrate excellent oral, written and interpersonal skills. Ability to demonstrate critical thinking, problem solving and excellent organizational skills. Ability to work productively and effectively in a complex environment that includes multiple changing priorities. Demonstrated ability to work well with physicians and other healthcare professionals in a direct and positive manner. Proficient computer/Microsoft-suite skills and previous Epic EMR experience. Ability to handle multiple responsibilities. Physical Requirements and Working Conditions: Position may require travel between clinic sites so there may be exposure to road and weather conditions. Manual dexterity required for operation computer and calculator. Visual acuity required to facilitate review of written documents/computer screens, medical records, and to record information accurately. Clear oral communications and hearing acuity required for receiving instructions and converse on standard telephone. Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone. Exposed to normal office environment; including usual hazards related to operating electrical equipment. Operates all equipment necessary to perform the job. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. Advocate Aurora Health is one of the 10th largest not-for-profit, integrated health systems in the U.S. with nearly 3 million patients served at more than 500 sites of care in Illinois and Wisconsin, including 28 hospitals. We're redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in a variety of specialties. Advocate Aurora Health is one of the 10th largest not-for-profit, integrated health systems in the U.S. with nearly 3 million patients served at more than 500 sites of care in Illinois and Wisconsin, including 28 hospitals. We're redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in a variety of specialties. This is Transformation One shared purpose brought us together. Now, as one of the 10 largest not-for-profit, integrated health systems in the United States, our combined strength and stability drives us forward. Starting with You Caring for nearly 3 million people has inspired a transformation. One in which the patient’s experience guides our vision and empowers us to offer new possibilities in our communities. Reshaping Access What is access? It’s offering more sites of care than any other health system in the Midwest. But there’s a new frontier. Access is exploring the latest technologies to deliver care to patients exactly where they are and exactly when they need it Inspiring Professionals With our dynamically inclusive workforce and strong connections to the places where we live and work, we’ll touch more lives and contribute to stronger and more vibrant communities. Transforming Care We’re redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in: Cardiovascular Care Neurosciences Gynecology Oncology Pediatrics Primary Care Neurology Geriatrics Trauma Care