Diabetes Health Coach - Full-time / Part-time

SUMMARY: Works as part of an interdisciplinary team to help patients and families with the management of diabetes. Assists in identifying and helping patients overcome risks and barriers which predispose to illness, or which interfere with obtaining maximum benefits form medical care with an ultimate goal of improving adherence, supporting self-management skills, and achieving unparalleled health outcomes. REQUIREMENTS: Work in close collaboration with physicians, certified diabetes educators and other health care personnel in patient evaluations and treatment to further their understanding of significant social and environmental factors underlying patient’s diabetes and other chronic health problems. Develop care plans with patients, diabetes multidisciplinary team, significant others and community providers Document all patient services in patients electronic medical record, closes encounter within 48 hours Participate in development of other staff members Continuous collaboration with diabetes multidisciplinary team in the care delivery to patients and their families around the care of chronic illness Creatively approaches outreach and diabetes care services for patients with diabetes who are hard to engage or are lost to follow up. Follows up with patients who have not attended CDE visits, have not completed ophthalmology referral, were recently discharged from the hospital, and participates in discharge care planning. Actively utilizes IFH stats to monitor and track quantitative measures to monitor patient’s progress such as A1C, PHQ9, blood pressure, cholesterol and weight; documents progress in patient’s record and discusses with patient. Collaborate with patient and diabetes multidisciplinary team to improve measures and outcomes. Reinforces SMART goals with patients and utilize SMART in development of plans and patients. QUALIFICATIONS: Bachelor’s Degree in Social Work, Counseling, Public Health , Human Services or Psychology Ability to write reports and correspondence Bilingual (English /Spanish) required Knowledge of Social Services agencies and resources in the NYC area Equal Employment Opportunity/Affirmative Action: The Institute for Family Health is an Equal Employment Opportunity Employer. This job summary is intended to be brief and may not list all the duties and functions required, however, it does highlight the essential requirements. Nothing outlined in this job summary is to be construed as an express or implied contract of employment. Please visit www.Institute.org for more information.