Would you like the opportunity to empower people w/ health knowledge so they become active partners in their care? Then consider exploring an opportunity at APS Healthcare, a health services organization dedicated to making a significant, positive impact on the healthcare system by changing behaviors and improving clinical and financial outcomes.

Our new Portland based office is seeking a Community-based Health Coach (CBHC) to impact the overall health and well being of our clients by working with high risk Medicaid beneficiaries to improve health and prevent hospitalizations. Casework is focused on establishing and stabilizing social and healthcare support structures. The CBHC will work in various hospitals, health centers, the APS field office and in certain instances of high acuity, a member�s home. Caseloads will be built primarily through face-to-face engagement in hospitals, clinics, and other community locations. The CBHC establishes a therapeutic alliance and gains the trust of the beneficiary, his/her family/support network, and providers.

Responsibilities:
� Conducting on-site healthcare facility visits to facilitate quality of care.
� Assess the client and develop a care plan, focused on assuring a) adherence to hospital discharge instructions(e.g. prescriptions, doctor visits), b) a stable living environment, c) a medical home (e.g. primary care physician or clinic), d) medication compliance, e) palliative care (if appropriate), and f) other related services (e.g. transportation to physician/clinic).
� Successfully execute the care plan, primarily through contact (telephonic or face-to-face) with the beneficiary, family/support, providers, state and community agencies and other resources.
� Coordinate services, and assess progress and outcomes.
� Provide education on the disease process.
� Meet performance standards.
� Attend and participate in case conferences.

Education:
Bachelor�s degree in Nursing, Social Work, Psychology or related field required. Master�s degree in Social Work, Counseling, Nursing or other healthcare discipline preferred

Requirements:
� Requires three to five years in a Health Care setting, such as hospital, clinic, or home health delivery.
� Experience & comfortable working in hospital settings; familiarity with discharge planning.
� Experience working with individuals with serious mental illness (e.g. schizophrenia, major depression, bipolar)
� Knowledge of community based resources.
� Outstanding interpersonal skills. Able to gain trust of patients and establish strong working relationships with health care and social service professionals. Equally comfortable face-to-face and on the telephone.
� Able to work with a high degree of independence; self-starter, highly motivated.
� Excellent assessment, problem solving, and prioritization skills
� Excellent computer skills
� Identify problems and craft solutions
� Knowledge of workflows; using and adjusting them to achieve set goals.
� Ability to establish and use metrics to analyze results and adjust work flow to achieve set goals.
� Does require moderate walking/standing for long periods of time.
� Position requires ability to travel within assigned geographic area