Role Overview:

The Coach advocates for, empowers, and educates clients.

Responsibilities:

1. Manage clients transitioning from acute/sub-acute hospitals or Skilled Nursing Facilities to home, or those needing care coordination, short-term care management, or assessments.
2. Handle referrals from payors.
3. Meet credentialing requirements in hospital or health care payor systems.
4. Use motivational interviewing and coaching tools for hospital visits and home visit preparation (if applicable).
5. Conduct post-discharge home visits within 48 hours (if applicable).
6. Perform in-home or telephonic assessments, HomeMeds (if applicable), and create care plans (if applicable) based on health care contracts.
7. Follow up on care coordination interventions promptly.
8. Identify and coordinate client support systems, including timely primary care physician visits post-hospitalization.
9. Develop a community-based referral network and review community resources and social service agencies.
10. Create and maintain systems to support ongoing program operations.
11. Collaborate with internal and external team members in care transitions.
12. Address crisis situations with timely and appropriate interventions.
13. Adhere to legal, departmental, health plan, and hospital regulations.
14. Build positive community interactions and referral relationships, seeking new resources.
15. Maintain effective interpersonal communication:

• Clear verbal and written communication.
• Resolve conflicts and unusual situations.
• Foster positive relationships and team building.
• Timely documentation and correspondence.

16. Demonstrate professional work habits:

• Organize workload and prioritize effectively.
• Complete assignments on time.
• Keep client files updated and accessible.
• Use resources efficiently.
• Comply with departmental expectations and productivity standards.
• Show initiative and adaptability to change.