RN Health Coach- WellMed - Round Rock, TX

The Health Coach is responsible for carrying out day-to-day support duties and facilitating teaching related to the Chronic Care, Congestive Heart Failure, Ischemic Heart Disease, COPD/Asthma and Diabetes Programs.  The RN Health Coach works in conjunction with the Disease Management team, physician advisors to the program, clinic staff and primary care physicians. This position assists in providing patient empowerment through the use of motivational interviewing skills, problem solving and self-management goal setting.

Primary Responsibilities:

• Works with the PCP and clinic staff to identify patients with high risk diagnoses such as CHF, IHD, COPD/Asthma and Diabetes and ensures clinical guidelines are being followed


• Conducts Chronic Care Model visits and reviews the patient's informal and formal support systems, focusing on what patients want to improve and educating them about their chronic disease


• Utilizes appropriate motivational interviewing techniques necessary for coaching and assisting the patient to complete self-management goal/action plans


• Enters timely and accurate data into the Disease Management Database, PsiMed, SmartClinic and other applications necessary to communicate patient needs and to ensure complete documentation of patient visits and phone calls


• Pulls tasking report from disease management database and conducts Chronic Care Model follow-up phone calls to eligible CCM enrolled members who have set self-management support goals within 2 weeks of date tasked.  Ensures all delegated tasks are also completed within 2 weeks of date tasked.  Tracks self-management goal outcomes and documents in disease management database


• Maintains current knowledge regarding CHF, IHD, COPD/Asthma and Diabetes as well as treatments and medications related to each


• Establishes a trusting relationship with identified patients, caregivers, clinic staff members and physicians


• Conducts clinic one-on-one visits with Disease Management Chronic Care Program participants—utilizing the Chronic Care Model—to assess patient needs for DME, home health, value-added services and any other necessary resources.  Communicates these needs to the appropriate person (i.e. Social Worker, clinic staff, etc.) or addresses them per process


• Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives.  Decision making is usually based on prior practice or policy, with some interpretation.  Applies individual reasoning to the solution of a problem devising or modifying processes and writing procedures


• Serves as a resource or consultant for LVN team members


• Attends educational offerings to keep abreast of change and complies with licensing requirements, ensures all patient educational materials are up-to-date, and maintains knowledge of specialty and ancillary provider contract contents, to include exclusions and contract terms


• Collaborates with the nurse manager to recommend policies, procedures and standards which affect the care of the patient with high-risk chronic disease diagnoses such as CHF, IHD, COPD/Asthma and Diabetes


• Exhibits professionalism and is courteous with all patients, physicians and co-workers


• Performs all other related duties as assigned

Required Qualifications:

• Registered Nurse with a current license to practice in the state of employment


• Two or more years experience in a physician's office, clinical or hospital setting


• Cardiac, medical-surgical and/or critical care experience


• Proficient knowledge of chronic diseases, especially COPD/asthma, diabetes, CHF and IHD


• Experience related to patient education and/or motivational interviewing skills and self-management goal setting


• Excellent verbal and written skills


• Ability to interact productively with individuals and with multidisciplinary teams


• Proficient computer skills, including Microsoft Word, Excel, Access and Outlook


• Excellent organizational and prioritization skills


• Ability to lift up to 50 pounds


• Ability to push or pull heavy objects using up to 100 pounds of force


• Ability to sit for extended periods of time


• Ability to use fine motor skills to operate office equipment and/or machinery


• Ability to receive and comprehend instructions verbally and/or in writing


• Ability to use logical reasoning for simple and complex problem solving

Preferred Qualifications:

• Knowledge of managed care, referral processes, claims and ICD-9 and CPT coding


• Bilingual (English/Spanish) language proficiency

WellMed is a healthcare delivery system serving more than 90,000 patients, primarily Medicare eligible seniors, in Texas and Florida through primary care clinics, multi-specialty clinics, and contracted medical management services. Headquartered in San Antonio, Texas, WellMed is an industry leader in medical risk management, highly effective disease management and chronic care programs, healthcare delivery services and more.

Our focus and mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. We are innovators in preventative healthcare, striving to change the face of healthcare delivery for seniors. Our providers and support staff are selected for their dedication to the senior population and focus on preventative, proactive patient care.

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.

Job Keywords: Registered Nurse, RN, Chronic disease management, chronic illness, disease management, chronic care, preventative care, Seniors, Clinic, Round Rock, TX, Georgetown, TX, Austin, TX