Chronic Care Coach

Gettysburg, PA | Physician Practices | Tracking Code: 68888

Schedule & Location

Hours: Full Time/Day shift (80 hours every 2 weeks) 

Location: 37-39 N. Fifth St. Gettysburg, PA 17325

Job Description:

Under the general supervision of the Ambulatory Care Management team leadership, provides coaching services to patients. Supports the care team by functioning as a coach for disease prevention and early screening, testing and treatment. Helps patients manage their chronic diseases. Assists in the care of patients, and instructs patients and their families in appropriate care, as directed by their provider. Functions as a member of the Ambulatory Care Coordination Team (CCT) to assist in the planning and implementation of patient care based upon sound clinical preparation, knowledge, skills and experience. Care is provided in accordance with the provisions of Clinical Medical Assistant Certification or Practical Nurse Licensure with the Pennsylvania State Board of Nursing.

 

Duties and Responsibilities

  1. Provides support to patients of the practice for clinical outcome management; healthy lifestyle information, via appointment coordination and navigation of the health system.
  2. Supports the care team by functioning as a coach for disease prevention, early screening and testing and treatment and for helping patients manage chronic diseases.
  3. Generates/review care management risk lists of patients in order to proactively manage patients and families with service needs for prevention or chronic conditions.
  4. Participates in daily huddles with Ambulatory CCT members for review of at-risk patients, follow up on issues and review of patients in need of care management services.
  5. For patient populations where WellSpan Health is at financial risk, provides direct care management interventions by completing the Shared Care Plan. Interventions include: assisting patients with goal setting, creating action plans to manage their health, addressing barriers to patient adherence to treatment plan, assisting patients with referrals utilizing wellness and self-management programs.
  6. Uses Motivational Interviewing techniques to engage patients in self-management skills.
  7. Assists patients with instruction and health literacy through teach back of any new medications, instructions and referrals. Monitors outcomes while following up on interventions identified in the care plan within scope of practice. Provides health care information materials and reviews with patient and or family members as directed by providers.
  8. Maintains the patient’s records to ensure an accuracy of the patient’s medical treatment. Documents in the patient record under the direction and supervision of the care provider.
 

Nonessential Accountabilities:

  1. Attends meetings as required.
  2. Performs other related duties as identified.
 

Common Expectations:

  1. Demonstrates a commitment to patients, visitors and staff by: complying with all applicable safety regulations; learning the impact of medical errors and methodology that will lead to reduction of errors; reporting actual and potential errors, as well as hazardous conditions; identifying opportunities to standardize processes and "error proof" systems that will lead to increased safety; and participating in safety education programs and root cause analyses as required.
  2. Maintains established policies and procedures, objectives, quality assessment, safety, environmental and infection control standards.
  3. Maintains the cleanliness of work areas as required.
  4. Maintains professional growth and development.
  5. Enters and/or retrieves data from established computer files using knowledge of various computer software applications.
  6. Provides outstanding service to all patients, providers, coworkers and customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
 

Qualifications

  • Notes:
    • Other combinations of formal education, training and experience may be considered.
  • Minimum Experience:
    • 2 - 3 years
  • Minimum Education:
    • Advanced level Medical Assistant.
  • Preferred Education:
    • Licensed Practical Nurse (LPN)
  • Required Certification:
    • Medical Assistant Certification or LPN licensure
    • Req Courses/Training: Completes all required education programs and competency testing needed to perform at an advanced level; medical terminology
  • Physical Demands:
    • Prolonged periods of standing/walking
    • Occasional sedentary work
    • Lifts supplies, files and equipment
    • Occasionally lifts, positions, pushes and/or transfers patients
    • Periodic reaching, stooping, bending, kneeling, crouching
  • Skills:
    • Proficient communication skills including SBAR technique; Ability to effectively present clinical information to the care team; Proficient in navigating and entering information into an electronic health record; Models team work; Self-motivated and dependable; Able to work independently.
Marcus Schneider
Marcus Schneider
Sr. Talent Acquisition Consultant
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Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Established in 1800, Adams County includes the borough of Gettysburg, Pennsylvania. Home to more than 100,000 residents, the town is a mecca for Civil War history buffs and visitors who come to tour the Gettysburg National Battlefield, Gettysburg National Military Park and see the annual Civil War reenactment.

Also located here is Gettysburg College, which has a strong academic reputation in liberal arts. The county is steeped in heritage, and offers a peaceful, country atmosphere, yet is a convenient drive to Washington, D.C., Baltimore, MD and Harrisburg, PA. The area's diversity attracts a lively local music scene, and his home to numerous restaurants and wineries, fresh-produce markets, a ski resort and more. Adams County residents can find local employment in healthcare, tourism, agriculture and manufacturing. (Patient population: 102,000)