The RN Health Coach performs on-sight visits and/or telephonic review of MO HealthNet Health and Wellness participants for health assessments and education. This position is based in the People's Heath Center clinic in St. Louis, MO and supports the Primary Care Physicians and/or Health Care Home in the participants Plan of Care (POC). The RN Health Coach assists participants in learning self-management of medical condition(s) and completes documentation of assessments and/or interactions with the participant. The position will require occasional travel between APS locations for training and education, including 2-3 weeks upon hire. Schedule is typically Monday � Friday, daytime hours with occasional evenings and weekends as needed.

Responsibilities:

Verify participant enrollment data including demographic information.

Review claims data to assist in identifying co-morbid conditions, hospitalizations, prescriptions, and other factors that could impact the educational and support needs of the individual.

Conduct health risk assessments during clinic visit or telephonically on individuals that fall under the Population Management Program.

Obtain verbal consent of the individual for participation in the program.

Identify problems, set goals, intervention and determine the individual�s health status based on assessment.

Establish goals/care plan for each individual regarding educational and health care needs.

Communicate with primary care and/or treating physician to request specific health information and/or to provide an update of an individual�s health care status.

Collaborate on an individual�s care plan in conjunction with other health professionals, such as a medical home, certified dieticians, behavioral health specialists, respiratory or physical therapists.

Perform follow up assessments, identify education materials needed, and make contact with an individual in a population management program as appropriate.

Prepare reports and case summaries as required.

Complete special assignments and projects instrumental to the function of the department.

Assist with development of training material.

Education/Requirements:

Registered Nurse with active Missouri license.

Minimum of 2 to 3 years clinical nursing background, including experience with quality improvement, medical record reviews, disease management and/or primary care case management.

Experience with chronic illnesses and disease states identified by MO HealthNet Division.

Effective verbal and written communication skills.

Ability to resolve problems in a non-threatening manner.

Ability to work independently without direct supervision.

Computer literacy and experience with Microsoft applications and health related software programs. Ability to learn new computer software.

Valid Missouri driver's license and auto insurance.