Our mission is Better Health. Our passion is helping others.

What’s Your Why?

• Are you looking for a career opportunity that will help you grow personally and professionally?
• Do you have a passion for helping others achieve Better Health?
• Are you ready to join a growing team that shares your mission?

Why Join Our Team: At Better Health Group, it’s our commitment, our passion, and our culture that sets us apart. Our Team Members make a difference each and every day! They support our providers and payors, ensuring they have the necessary tools and resources to always deliver best-in-class healthcare experiences for our patients. We don’t just talk the talk - we believe in it and live by it. Be part of a team that shares your passion and drive, and start living your purpose at Better Health Group.

Responsibilities & Experience

The Health Coach will directly support the Health Services Team. They will be expected to perform within the following scope, as well as other assigned duties and activities that aid and leverage our Team function. Responsibilities include and are not limited to:

• Communicating and facilitating Transition of Care Management (TCM) telephonically between patients and medical offices as assigned

  • Telephonic outreach to recently discharged patients; to assess patient needs and coordinate care

  • Thorough interview of assigned patients regarding discharge instructions and plans to include:

    • Educating patients to call Primary Care Physician (PCP) for all truly non-emergent services

    • Inquiring as to discharge planning and review of plan with Provider

    • Encourage and schedule post-discharge medication reconciliation with Provider

    • Review any dietary changes with Provider post-discharge

    • Review any self-care planned ie: durable medical equipment, home care, wound care, etc.

    • Assess patient at-home support system ie: caregiver or any persons identified as assisting them with any healthcare needs

    • Establishing whether or not patient has advanced directives in place and accessible to Provider and family in case of need (encouragement to do so, if not)

    • Obtaining status of seasonal vaccines

    • Scheduling or confirming follow-up with Provider, ideally within 7 days of discharge

  • Utilize plan benefits effectively; transportation assistance, nutritional support and other benefits as applicable

  • Responsible for reporting on TCM task completion and disposition of tasks as appropriate

  • Accurate and timely documentation provided to assigned PCP office champions

• Prepared to assist with telephonic outreach to external pharmacies, PCPs and patients for medication adherence; escalate to internal Clinical Pharmacist as appropriate

• Prepared to assist and engage in other telephonic outreach campaigns as directed by Better Health Group to include Medicaid, Medicare, fee for service, etc.

• Utilizing TCM  reports to prevent re-admissions for recently discharged patients

• Utilizing Complex Care Management reports to identify patients at risk for admission to hospital and strategize on preventative care options

• Escalate high risk patients to medical office champions, internal Utilization Management Nurse, internal Subacute Nurse and internal Field Ops team members as appropriate

• Daily operation of multi-line phone system to complete assigned tasks

• Daily operation and utilization of designated electronic medical systems for task completion and accurate documentation of call activities

• Act as liaison to encourage and empower patients to utilize primary care services

• Collaborate with internal and external teams to leverage care goals  

• Attend and participate in weekly Health Services meetings with Team

• Attend and participate in weekly 1:1 meetings with Sr. Manager of Health Services

• Build lasting relationships with medical office teams and obtain consistent  engagement/participation from assigned offices in scheduled huddles

• Communicate with medical office champions to monitor care provided to high risk patients

• Successful management and coordination of inbound and outbound calls

• Collaborate internally with Field Operations, Quality Operations and Stars teams to leverage utilization management goals

• Outreach and collaboration to external medical offices, hospitals and SNF to assist, facilitate and leverage care goals

• Other designated administrative, clerical or operational tasks as assigned to leverage Better Health Group goals (ie: medication adherence initiatives, PODS, members not seen, etc.)