Care Transitions Health Coach

Job Overview: 

The Care Transitions Health Coach is responsible for providing services to eligible patients aimed at preventing hospital readmissions. This role emphasizes empowering patients to manage their chronic conditions through education, self-advocacy, and guidance on navigating complex healthcare systems. The Health Coach ensures patients are informed about available supports and services through The Span Center and facilitates necessary referrals to community partners. This role also includes supporting and the implementation of the MVP program by providing intensive, relationship-based support to adults with frequent hospital admissions or emergency department use. The CT Coach serves as the primary point of accountability, helping stabilize medical, behavioral health, and social needs through home visits, care coordination, and system navigation. This approach emphasizes engagement, trust-building, and problem-solving, rather than short-term discharge planning.

Supervision: 

Performs work under the direct supervision of the Care Transitions Program Manager.   

Duties/Responsibilities: 

• Receives Care Transitions referrals directly from referral source.
• Assess patients for eligibility in the Care Transitions program by reviewing medical records, consulting with hospital care coordinators and social workers or other medical personnel and conducting patient interviews.
• Facilitate effective care transitions by providing guidance and support to patients and their families, helping them understand their health conditions and care options.
• Conduct in-person and telephone visits to promote patient self-care management, utilizing coaching tools such as the Personal Health Record.
• Identify and address medication discrepancies, assisting patients in reconciling these with their physician or pharmacist.
• Educate and coach patients to recognize signs and symptoms of worsening conditions and take appropriate actions.
• Encourage patients to attend scheduled appointments with their primary care physician and other necessary healthcare professionals.
• Enter client information and interactions into PeerPlace and other data systems used by the Care Transitions program.
• Provide information about The Span Center and other community resources, referring patients for further advanced care counseling as needed.
• Proactively seek and cultivate additional referral sources to expand the program, while promoting Senior Connections services to physician practices, facilities, and supportive services.
• Actively engages in professional development programs and monthly supervision meetings.
• Attends meetings and training sessions to enhance knowledge and skills.
• Prepares and maintains reports, records, and files using modern computer automation technology.
• Participates in advocacy efforts to support and address the diverse needs of the communities we serve.  
• Supports opportunities for community volunteers to engage with relevant aspects of their department or program, with support from Volunteer Services Staff. 
• Performs other duties as assigned.

Knowledge, Skills, and Abilities:

• Understanding laws and regulations related to patient care and transitions.
• Familiarity with care transition models and best practices.
• Knowledge of local healthcare services, support groups, and resources available for patients.
• Strong verbal and written communication skills to interact effectively with patients, families, and healthcare providers, other staff, and the general public.
• Ability to assess situations and develop effective solutions for patient care transitions.
• Proficiency in managing multiple cases and maintaining accurate records.
• Ability to understand and respond to the emotional needs of patients and families during transitions.
• Capacity to work effectively with interdisciplinary teams and community partners.
• Flexibility to adjust to changing patient needs and healthcare environments.
• Ability to conduct interviews, analyze facts, and exercise sound judgment.
• Ability to prepare reports and maintain case records using computer automation technology.
• Excellent interpersonal skills.
• Must have ability to travel
• Valid driver’s license required

Education and Experience:

• A Master of Social Work (MSW) or a graduate degree is a plus. A Bachelor’s Degree in a health-related field, such as nursing or social work, is required, along with at least two years of relevant experience.

Physical Requirements:

• Prolonged periods sitting at a desk and working on a computer.
• Prolonged periods of sitting behind a vehicle for travel time within our planning district.
• Must be able to lift up to 15 pounds at times.

The Span Center is a trauma-informed, person-centered agency dedicated to fostering a safe and supporting environment for both our employees and the communities we serve.    

The Span Center prohibits discrimination on the basis of race, color, religion, national origin, sex, pregnancy, childbirth or related medical conditions, age, marital status, disability, sexual orientation, gender identity, genetics, political affiliation, or military status in the recruitment, selection, and hiring of its workforce. 

Salary : $46,800 - $52,000