Health Coach (5 positions available)

Position OverviewThe Health Coach serves as a core member of an integrated care team working to expand access to care, improve care coordination, and reduce health disparities. The role supports grant-funded rural health initiatives through patient engagement, behavior change coaching, community resource navigation, and accurate program reporting.Using a patient-centered, evidence-based approach, the health coach helps patients at high risk for poor health outcomes and individuals living with multiple chronic conditions (including, obesity, diabetes, and cardiovascular disease) set self-directed goals and build sustainable daily habits. The coach connects clinical treatment plans with everyday self-management and helps patients overcome barriers to participation in care.We will also consider individuals who are able to work remotely.Key ResponsibilitiesPatient Engagement and Chronic Disease Self ManagementConduct initial and ongoing coaching intake conversations and non-diagnostic assessments of patient priorities, readiness for change, daily habits, and barriers to care. Establish baseline goals and program measures using approved tools.Partner with patients to develop achievable action plans that support disease self-management.Use motivational interviewing, active listening, and strengths-based coaching to support medication-taking routines, physical activity, sleep, stress management, and nutrition goals established with the care team.Provide regular follow-up, review progress, and help patients adjust their goals. Involve family members or caregivers when appropriate and with the patient’s permission.Deliver culturally responsive education using approved materials and teach-back methods. Facilitate evidence-based workshops and group coaching on prevention, wellness, and chronic disease self-management.Care Coordination and Community ResourcesIdentify social determinants of health and connect patients with food assistance, transportation, housing, financial assistance, and other community services. Follow up on referrals to help patients access needed support.Collaborate with specialists, primary care providers, care managers, registered dietitians, behavioral health professionals, community health workers, and other team members to align coaching goals with treatment plans and avoid duplication of services.Build relationships with community organizations and participate in outreach activities to engage patients who face geographic, technology, or other barriers to care.Documentation and Program ImprovementDocument patient contacts, goals, action plans, referrals, and progress accurately and promptly in the electronic health record (EHR) and designated program systems.Collect and compile enrollment, retention, participation, referral completion, approved outcome measures, and patient satisfaction data to support grant reporting. Meet program documentation standards and reporting deadlines.Participate in team meetings and quality-improvement activities; use patient feedback and program data to improve engagement, access, and coordination.Technology and Professional PracticeHelp patients use telehealth platforms, approved remote patient monitoring devices, and digital health tools. Address basic access or usability barriers and refer technical or clinical questions to the appropriate team member.Protect patient privacy and follow institutional policies, applicable confidentiality requirements, grant requirements, and established documentation and safety procedures.Work within health coaching training and assigned responsibilities. Refer symptoms, medication questions, abnormal monitoring results, and other clinical concerns to licensed clinicians according to established protocols. The role does not independently diagnose, prescribe, adjust medications, or provide medical nutrition therapy.