• Community Health Coach - HGN ACO - Essex County, NJ

    Job Locations US-NJ-Essex County
    Posted Date 3 weeks ago(3 weeks ago)
    # of Openings
    Regular Full-Time
  • Overview

    VNA Health Group is a premiere Medicare/Medicaid-certified provider of home health, hospice, and community-based services. We’ve been serving families and individuals with the most advanced and comprehensive clinical home care in NJ since 1912. 


    This position will be a VNA Health Group Employee Assigned to

    Healthy Greater Newark Medicaid Accountable Care Organization


    About Healthy Greater Newark Accountable Care Organization (HGN ACO): HGN ACO works to improve health outcomes and responsibly control costs through increased coordination across health providers and community partnerships, facilitated by data exchange, provider engagement and patient education and navigation.


    Position Summary: Under general supervision, the Community Health Coach provides basic care coordination, identifies and reduces barriers to care and provides referrals to necessary resources. The Community Health Coach will be based out of a federally qualified health center and may provide follow up phone calls, visits to patients and their families to help teach and train in areas of health logistics and other life and wellness skills to manage their health, accompaniment to medical and social service appointments and conduct group education activities. The Community Health Coach will work under the supervision of the Care Team Facilitator.


    • Addresses gaps in care of patients – effectively work with individuals from diverse backgrounds in reducing cultural and socioeconomic barriers between clients and institutions
    • Assesses and identifies actual and potential patient problems and barriers to care by gathering relative data; Identifies and assists clients in reducing barriers to care
    • Provides effective, productive, and professional communication between patients, providers and supervisor; Uses knowledge of client's cultural, ethnic, religious and social system to develop and revise care
    • Educates and assists patients in the management, prevention, and maintenance of their health and wellness
    • Builds and maintains relationships with both internal and external healthcare contacts and organizations in an effort to improve available patient resources
    • Collaborates with members of delivery team (Doctors, Social Workers, Nurses) to identify concerns that would prevent quality medical care; Communicates client plans and concerns to healthcare providers
    • Assesses patient needs; Assists in coordinating patient care
    • Establishes positive, supportive relationships with patients/clients in managing their health care needs
    • Provides comprehensive case management
    • Tracks patient outcomes and provides information to authorized personnel as requested
    • Provides referrals for services to community agencies as appropriate
    • Acts as a patient advocate and liaison between the patient/family and community service agencies (i.e. schools, Department of Health, hospitals, support groups, etc.)
    • Conducts one-on-one education at every opportunity
    • Enters accurate and complete data within 24 hours of client interaction
    • Ensures confidentiality of patient information by creating and maintaining a secure and trusting environment by not sharing information learned on the job, except when necessary in the performance of the job responsibilities or to improve a patient’s care
    • Has regular and predictable attendance
    • Other duties as required


      • Minimum BA and/or significant record of relevant professional experience
      • Typically requires at least one year of community involvement and/or working with clients, or an equivalent combination of education and experience. Public health, healthcare and/or social services experience or education; Case management experience preferred
      • Knowledge, Skills & Abilities:
        • Knowledge: Basic care coordination, knowledge of community resources
        • Skills: Establish and maintain rapport and a therapeutic relationship, Communication and motivational interviewing, uses computers, including Microsoft Outlook, Word, Excel, scheduling software as well as perform Web searches for clients; Excellent verbal and written communication skills with focus on quality customer service
    • Valid NJ driver’s license and/or reliable transportation
    • Knowledge of cultural and lifestyle diversity issues with ability to network with a specific population
    • Ability to work both independently and as part of a team; Strong organizational, case management and interpersonal skills
    • Successful completion of a Health Coach or related formal training program such as from a college or other education institution is preferred


    Desired qualities:

    • Commitment to serving the community
    • Caring about others
    • Warmth
    • Respect by peers in the community
    • Shared values and experiences of the people being served
    • Membership in the community being served
    • Good health practices, attitudes, and self-esteem
    • Ability to take a stand for what they believe
    • Ability to grow, change, and learn, and
    • Leadership in the community   
    • Working Conditions/Physical Demand: Various community settings including some visits to community locations; able to drive a car; use a desktop computer/laptop, cell phone, other office machines such as fax, copy, and scanner

    Hours: This is a full-time position that requires the ability to work a flexible schedule. General daytime hours: Monday – Friday; possible weekends or evenings as needed


    Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
    Share on your newsfeed

    Need help finding the right job?

    We can recommend jobs specifically for you! Click here to get started.