Job Description

Population Health And Disease Management Support

Provides population health and disease management support to defined populations including commercial payors, external businesses, and Jefferson Enterprise health plan(s). Supports members with chronic conditions meet their health needs and intervenes to help members and providers manage chronic conditions using evidence-based research and best practices while ensuring alignment with accreditation and compliance standards. Provides one-on-one clinical coaching including assessment of participant health status, collaboration with participants to develop a personal care plans, and support of individuals to adhere to their care plan to achieve and maintain optimal health.

Job Duties

• Conducts telephonic, virtual, or in-person clinical health coaching and outreach per the condition support/disease management program guidelines and accreditation standards.
• Triages and assesses participant health status by completing clinical assessments using data from claims, medical records, clinical judgment, and participant feedback to identify care gaps and guide member-centered goal setting.
• Implements appropriate interventions based on risk level and works with members to identify healthy lifestyle changes, set person-centered goals, and develop individual care plans while providing support and accountability.
• Utilizes clinical knowledge and applies evidence-based measurement, behavior change techniques, and outcome planning to achieve outcomes.
• Identifies actual and potential risk to patients and takes appropriate action to minimize risk including knowledge gaps and medication adherence concerns.
• Increases quality of care and engagement with providers by providing, tracking, and following-up on referrals to medical and social services.
• Identifies opportunities and collaborates with members and the care team to implement strategies to decrease utilization of unnecessary medical services, hospital admissions and emergency room visits, and disease complications.
• Drives engagement, evaluation, and improvement of the condition support/disease management programs.
• Assists other departmental professional staff in fulfilling and delivering high quality health improvement programs.

Minimum Qualifications

• Bachelor's Degree in nursing
• 2 years of experience in medical-surgical acute care, cardiology, pulmonology, respiratory, and/or endocrinology settings and
• 2 years of experience in medical management, case or disease management, health insurance, or related field and
• 2 years of experience as a health and wellness coach or clinical coach and
• 2 years of experience working with behavior change models such as readiness to change, motivational interviewing, goal setting, and resolution techniques to assist participants in developing individualized plans for successful behavior change.
• Ability to recognize co-morbidities and barriers to assist participants in creatively breaking down barriers into manageable obtainable steps.
• Demonstrated knowledge of the disease process and disease management.
• Demonstrated ability to locate and link individual to network and community health care resources.
• Strong time-management skills and ability to handle multiple priorities.
• Strong desire to educate, motivate, and support individuals with risk areas in weight management, tobacco use, nutrition, physical activity and/or stress management, work/life balance, and general health.
• BLS - Basic Life Support AHA - American Heart Association within 1 Year
• WC - Wellness Coach - National Board for Health & Wellness Coaching within 1 Year
• DL - Driver's License_PA - State of Pennsylvania Upon Hire
• RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire

Preferred Qualifications

• Master's Degree in nursing, public health, social work, nutrition, or psychology and
• training in motivational interviewing, active listening skills, and application of the transtheoretical model.
• Excellent computer skills in electronic medical record (EMR).

Additional Qualifications

Physical Demands Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Work Shift Workday Day (United States of America)

Worker Sub Type Regular

Employee Entity Thomas Jefferson University

Primary Location Address 1101 Market, Philadelphia, Pennsylvania, United States of America

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