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Health Coach

A Health Coach is a healthcare professional who provides face-to-face and telephonic coaching for patients with complex, chronic or multiple co-morbid medical and behavioral conditions in a
primary care setting. The population focus is on individuals who have been diagnosed with chronic conditions and have multiple barriers impeding their ability to engage in healthy lifestyle
behaviors. The Health Coach will help patients gain the knowledge, skills, tools and confidence to become active participants in their care to reach their healthcare management goals. The work
of the Health Coach is performed independently and reviewed through observation, conferences and results achieved.

PRIMARY RESPONSIBILITIES:
1. As a key member of the patients' clinical team, work closely with the patient and the their family members in evaluating present health management program, advocate for the
patients' treatment preferences and make recommendations in formulating a plan for the patients' future healthcare needs.
2. Exercise and use discretion to create individualized plans of care for the patient.
3. Provide coaching, education, support and identify advocacy needs.
4. Utilize motivational interviewing and engagement strategies to support and improve the overall health and wellness of the patient.
5. Provide support to patients in order to help them identify a need for behavioral change to improve health status, reduce health risks and improve quality of life.
6. Educate and refer patients to available health and community resources when appropriate.
7. Follow up with the patient to ensure that program engagement has been achieved and assess additional needs.
8. Check to see whether medications are being taken as prescribed and whether the patient understands the importance of taking their medications consistently to promote and encourage treatment adherence.
9. Chair regular systematic clinical case reviews as an equal member of the clinical team focusing on newly identified patients and those who have not adequately improved based on specified timeframes and make treatment recommendations.
10. Maintain communication and periodic updates with patient's primary care physician and clinical team.
11. Collaborate with clinical team on ways to improve coordination of patient care.
12. Initiate relapse prevention plan with patients who are in remission.
13. Document patient encounters and track outcome measures.
14. Other duties as assigned.

PRIVACY & SECURITY RESPONSIBILITIES:
• Workforce Vigilance: Each MACIPA employee has a responsibility to watch for unauthorized use or disclosure of Protected Health Information (PHI) or Personal Information (PI), to act and prevent the action and to report suspected breaches of privacy and security policies to their supervisor and MACIPA's designated Privacy and Security Officers. MACIPA Workforce are required to attend MACIPA's Privacy and Security Training, sign a Confidentiality and Non-Disclosure Agreement and complete HIPAA webinar training on an annual basis.
• System Access Profiles & Controls: MACIPA assigns system access profiles to job titles based on how much information is needed to accomplish work responsibilities in
accordance with our Privacy and Security Policies and Procedures. The above statements describe the general nature and level of works being performed by
individuals assigned to this classification. This is not intended to be an exhaustive list of all responsibilities and duties required of personnel so classified.
SKILLS/KNOWLEDGE AND ABILITIES:
• Bachelor's degree in Social Work.
• At least 2 years' experience working in a social service or health care setting or equivalent educational learning and a demonstrated ability to work with individuals and families who may have complex social and clinical needs.
• Knowledge of patient advocacy, resources and the local community.
• Sensitivity to cultural and ethnic diversity required.
• Act as an educator, resource and advocate for patients and their families to ensure a maximum level of independence.
• Proficiency in computer use, internet and health information technology.
• Ability to travel frequently to patients' homes, PCP office practices and other sites where
patients receive care.
• Develop positive working relationships in order to work collaboratively on plan of care.
• Assist in providing patient empowerment through the use of motivational interviewing skills, problem solving and self-management goal setting.
• Attend meetings, including some early morning or evening meetings.
• Effective communication and problem solving skills.
• Excellent oral and written communication abilities and possess strong relationship building skills.
• Self-motivated and able to organize and work independently with minimum supervision.
• Exercise discretion and independent judgment with respect to matters of significance.
• Current Massachusetts driver's license and own vehicle.

ESSENTIAL ABILITIES
1. Sufficient clarity of speech and hearing, with or without reasonable accommodation, which permits the employee to communicate well with the supervisor, community, employees and general public.
2. Sufficient vision, with or without reasonable accommodation, which permits the employee to produce and review a wide variety of materials, written correspondence, reports and related materials in electronic and hard copy form.
3. Ability to lift, move or carry objects up to 10 pounds regularly.
4. Ability to ascend or descend stairs or ramps using feet and legs, hands and arms.
5. Ability to maintain body equilibrium to prevent falling when walking, standing or crouching.
6. Ability to travel to and from various locations.
7. Ability to learn and carry out the primary responsibilities of the assigned position.
8. Ability to effectively communicate in writing and orally on job progress and other assignments and responsibilities.
9. Ability to conceive and articulate plan, create and manage detailed projects, organize and prioritize work.
10. Ability to analyze data and exercise sound judgment in making decisions and managing confidential or sensitive information.

MACIPA is an Equal Opportunity Employer (EOE) and all qualified applicants will receive
consideration for employment without regard to race, color, religion, sex, national origin, disability
status, protected veteran status, gender identity, sexual orientation or any other characteristic protected
by law.
Reasonable accommodations may be made to enable qualified individuals with disabilities to perform
essential functions (primary responsibilities) of this job. This job description is not intended as, nor
should be construed as, exhaustive of all responsibilities, skills, efforts, or working conditions associated
with this job.

This job description is not intended to limit or in any way modify the right of management to assign,
direct, and control the work of employees. The listing of duties and responsibilities shall not be held to
exclude other duties not mentioned that are of similar kind or level of authority.
MACIPA reserves the right to revise this job description at any time.