GENERAL SUMMARY: Under the general supervision of the Health Coach Supervisor and/or the Practice Leadership Team, provides safe, therapeutic and efficient care and services to patients. Supports the care team by functioning as a health coach for disease prevention and early screening, testing and treatment. Helps patients manage their chronic diseases. Assists in the care of patients, and instructs patients and their families in appropriate care, as directed by their provider. Functions as a member of the Care Coordination Team (CCT) to assist in the planning and implementation of patient care based upon sound clinical preparation, knowledge, skills and experience. Care is provided in accordance with the provisions of Clinical Medical Assistant Certification or Practical Nurse Licensure with the Pennsylvania State Board of Nursing. DUTIES AND RESPONSIBILITIES: 1 Provides support to patients of the practice for clinical outcome management; healthy lifestyle information, via appointment coordination and navigation of the health system. 2 Completes follow up calls to patients discharged from Hospital/ED and thoroughly documents. Arranges seven day follow-up and identifies issues and concerns to appropriate staff. Maintains report for seven day follow up outlying patients. 3 Communicates and shares information with providers and CCT members on issues and concerns such as transition of care between hospital, skilled nursing facility, rehab and home care. Supports the care team by functioning as a health coach for disease prevention, early screening and testing and treatment and for helping patients manage chronic diseases. 4 Generates/review payer lists of patients in order to proactively manage patients and families with service needs for prevention or chronic conditions. 5 Participates in daily huddles with other practice CCT members for review of at risk patients, follow up on issues and review of patients in hospital or practice in need of CCT services. 6 For patient populations where Wellspan is at financial risk, provides direct care management interventions by completing the Shared Care Plan. Interventions include: assisting patients with goal setting, creating action plans to manage their health, addressing barriers to patient adherence to treatment plan, assisting patients with referrals utilizing wellness and self-management programs. 7 Assists patients with instruction and health literacy through teach back of any new medications, instructions and referrals. Monitors outcomes while following up on interventions identified in the care plan within scope of practice. Provides health care information materials and reviews with patient and or family members as directed by providers. 8 Maintains the patients records to ensure an accuracy of the patients medical treatment. Documents in the patient record under the direction and supervision of the care provider.