Population Health Coach

Novant Health

Job Description

The employees Number One job responsibility is to deliver the most remarkable patient experience, in every dimension, every time, and understand how he or she contributes to the health systems vision of achieving that commitment to patients and families.
This person works collaboratively with physicians, mid-level providers, staff and other health care professionals to provide a medical home and care coordination function across the health care continuum focusing on enhancing the patient experience and supporting the medical home. Is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum. Responsibilities include assisting the medical office staff in developing and coordinating a wide range of self-management support and disease management activities for the clinics affected patient population. Focus will be on the identified chronic diseases applicable to the assigned medical home offices. Success will be measured by the results of the process and outcome performance measures of the population of patients in the clinic. This position supports the Patient Centered Medical Home Concept by working closely with the clinic and the disease management navigators to develop systems and promote effective self management of chronic disease and assist patients with navigating the healthcare system. Position will serve as a coach for multiple medical home offices to continually evaluate and enhance systems to support patient experiences and enhance care coordination. Focus will be to enhance and sustain the medical home in recognized offices.


Education: Associate's degree required. Bachelor's degree preferred. Graduate of an accredited school of nursing, required. BSN, preferred.
Experience: Minimum of five years clinical experience in hospital, home health, or community setting with a recent focus on acute and/or chronic disease management required. Case management experience preferred.
Licensure/Certification/Registration: Current RN licensure in appropriate state required. CPR and current valid state driver's license required.
Additional skills required: Broad clinical knowledge base of multiple diseases and expected outcomes. Working knowledge of effective teaching techniques, applying adult learning principles. Ability to demonstrate coordination of appropriate educational materials for patients and their support systems. Knowledge of good business English, Spelling, and Math. Demonstrates appropriate professional nursing skills in the provision of preventive health maintenance and/or treatment of illness. Demonstrates a working knowledge of Novant Health and the physician office setting to act with providing connections across the system. Demonstrate appropriate clinical leadership skills as evidenced by previous work related activities and performances. Demonstrate the ability to work independently to assess and evaluate understanding of disease processes, treatment plans and/or lifestyle changes. Demonstrate appropriate communication, negotiating and networking skills. Demonstrate sound knowledge and appropriate decision-making skills for designated patient populations. Demonstrate appropriate organization skills. Demonstrate the ability to provide program specific outcomes. Demonstrate the ability to assess self learning needs and seek ways to meet own professional development by proactively educating self, participating in orientation and staff development activities, maintaining knowledge of clinical practice, issues, trends, technology and available community resources, and uses policies and procedures appropriates.

Employment Type




Apply Save