Do you have a passion for working with your community providing services that make a real impact on those recently hospitalized? If so, these roles may be ideal for you! Candidates with any experience in Human Services such as (Direct Care Workers, Social Workers, Home Health Aides) can be considered!

ADDITIONAL PERKS! Flexible schedules, guaranteed weekly hours, and benefits! Bonus opportunities as well throughout the year!

The Community Health Coach provides thirty-day interventions to targeted patients who are recently hospitalized. The primary role is to identify eligible clients, provide specialized intervention with the goal of preventing avoidable hospitalizations and to empower patients to be the leaders in their healthcare. To accomplish this, incumbent will function as an information and referral source, provide a thirty-day intervention to patients and work with hospitals and health plans to prevent readmissions. This Coach works as a member of the multidisciplinary health care team to assure that discharge planning critical paths are followed, providing for successful care transitions.

• Interacts with designated AAA staff, hospital staff and participants when active patients are admitted into the hospital.
• Consults with hospital discharge planner, physicians and multidisciplinary teams to identify patients who would benefit from the Program.
• Conducts assessments of need for community-based service and support and provides referrals.
• Actively consults and collaborates with hospital multidisciplinary team in planning and executing patient transitions.
• Actively engages patients and caregivers in the discharge planning process using valid and reliable instruments; including a discharge preparation checklist, personal health record, medication reconciliation process and plan for medical follow-up.
• Directs engagement with patients and caregivers to complete the discharge preparation checklist, personal health record, medication reconciliation, as well as identification of educational needs in chronic disease process and self-management skills.
• Visits patient daily at hospital to ensure that patient and family are fully engaged and prepared for care transition process, including necessary tools and competency in self-management skills.
• Provides additional coaching and education as necessary to assure transition is executed consistent with patient and caregiver goals.
• Visits patient within 48 hours of transition to home or other care setting to review care transition process including adherence with discharge preparation checklist, evaluation of self-management skills, medication reconciliation, caregiver knowledge and self-management skills. Recognizes and addresses red flags and plans for medical contact and follow-up.
• Establishes an ongoing plan for home visits and phone contacts specific to patient's needs.
• Tracks program and individual performance objectives and routinely reports on progress and outcomes.
• Actively participates in readmission reviews with hospital staff and health plans.
• Attends staff meetings and meets with supervisor regularly.

• Ability to apply various coaching methodology to cases.
• Strong understanding of a coaching model and the ability to train others in this discipline.
• Ability to interact and engage with participants/family members/caregivers/direct care workers.
• Demonstrated organizational skills.
• Ability to work independently with minimal supervision.
• Proficiency in Microsoft Office products.
• Ability to work non-traditional hours, as needed.
• Knowledge of geriatrics, home and community-based services and social services preferred.
• Working knowledge of chronic disease self-management.
• Experience participating on a multi-disciplinary health care team.
• Experience working with chronically ill patients to identify patient goals and outcomes and provide education necessary for patient self-management.
• Strong time management skills and ability to balance multiple responsibilities.
• Strong communication skills and ability to work collaboratively with other health care professionals to assure coordination and continuity of patient care.

1. Tuberculin Skin Test (TST) to be done in two steps, or documentation of a IGRA blood test (Interferon-Gamma Release Assays testing), within the past 12 months.