RN Health Coach - Transitional Care

RN Health Coach As an RN Health Coach - Transitional Care, you will provide health coaching to Oklahoma Medicaid members. Perform assessment and evaluations for individuals with health care needs by collecting medical and social information to assist in the development of a patient-centered action plan.
This role is hybrid with the potential to work in hospital at least one day per week. Hours will be 8:00 am to 4:30 pm Monday through Friday.

Essential Functions

• Perform assessment and evaluation of patients with chronic disease per client contractual obligations.
• May Evaluate the needs of individuals and families, obtain psychosocial history; assess needs, and link individuals and families with available psychological, health, and social services. 
• Collect detailed information including medical, social, and financial information to aid in facilitating the appropriate treatment plan consistent with the patient’s needs. This may include member interviews, complete assessments, and provide brief psychotherapeutic interventions.  
• Collaborate with health care providers and ancillary service providers to validate the appropriate individualized treatment and care plan that may include a person-centered approach to promote wellness, appropriate utilization, awareness, and understanding of condition self-management, and identify educational opportunities.
• Ensure data necessary to report standard measures is collected as discreet data elements in the EHR or disease registry database.
• Work with EHR or registry vendors to obtain data output files in defined formats.
• Actively engage with patients and families, utilizing motivational interviewing techniques.
• Teach self-management skills and supports patients and families with chronic disease.
• Coordinate care management activities across the care continuum. This may include on-the-spot counseling for members with an active mental illness or disability and/or family members patients and staff. 
• Coordinate activities across the care continuum and identify gaps in care. This may include transitional care and referrals to appropriate levels of care.
• Implement and teach quality improvement methods including Plan, Do, Study, Act, and use of data to office/clinic personnel and clinicians.
• Ensure appropriate composition of the QI team including clinical champion(s).
• Assemble data and information for regular reporting requirements maintaining confidentiality and sensitivity of protected health information.

Requirements

• Registered nurse in Oklahoma is required.
• Two or four-year degree in health care or a related field.
• 3+ Years of experience.
• Disease management experience.
• Certified Case Manager or similar advanced credentialing or ability to obtain certification within 2 years of hire. 
• We'd love it if you had experience with motivational interviewing. This role requires excellent communication skills and organization.
• Spanish-speaking candidates are preferred!
• We are unable to consider candidates outside of the United States, candidates in the state of California, or those in US Minor outlying islands and territories.

COMMITMENT TO SAFETYAs part of our commitment to health and safety, some roles may require additional health protocols (i.e. personal protective equipment or vaccination) Who We Are: Telligen is one of the most respected population health management organizations in the country.  We work with state and federal government programs, as well as employers and health plans offering clinical, analytical, and technical expertise. Health has changed a lot through our 50-year history, but what has remained constant is that we care deeply about who we serve and what we do. Our success is built on our ability to adapt, respond to client needs, and offer innovative solutions. Our business is our people and we’re looking for talented individuals who not only believe in our mission but who are ready to take ownership and make a difference in the lives of people, in the world of health. Learn more about who we are and what we do at www.telligen.com/about-us Are you Ready? We’re on a mission to transform lives and economies by improving health and getting there means following through on our values of Ownership, Community, Ingenuity & Integrity.  Ownership: As a 100% employee-owned company, our employee-owners drive our business, our solutions, and share in our success. When employee-owners grow and thrive, we all win.Community: Putting others first and being a good corporate partner wherever we work, and play makes us who we are. We Show Up. For our clients, for our communities, and for each other.Ingenuity: We’re a team of passionate professionals driven by hard work and big ideas. We understand that high-value bre