Date Posted
February 7, 2024
Full Time
Human Resources
Van Diest Medical Center
2350 Hospital Drive
Webster City, IA 50595, US
More Information

Job Details

Works collaboratively with physicians, staff and other health care professionals within his/her clinically integrated network (CIN) to provide comprehensive care management and care coordination across the health care continuum for the highest risk members within the CIN in order to improve outcomes and lower the cost of care.    An integral member of the health care team who works to ensure safety, best practice and high-quality standards of care are maintained.  Also works to ensure members are able to navigate through the health care continuum by improving the coordination of care and member/family experience.  Health Coach will coordinate a wide range of self-management support services as well as a wide range of community-based and health care support services for members.  Works with physicians, staff and other resources (including those external to the CIN) to address specific quality improvement/performance improvement initiatives.

  • Works with patients and families on Self-Management Support including:
    1. Setting short and long-term goals for self-management of chronic disease.
    2. Addressing medication adherence in patients not meeting outcome goals.
    3. Working with patient to create a plan for Health Behavior Change utilizing the 5A’s approach
      • Assessing and working on the patient’s readiness to change, the importance of change, and confidence in ability to change.
      • Helping the patient to identify and overcome barriers
      • Optimizing member and family independence through coordinating and ensuring the provision of available and necessary resources to access the health care delivery system across the continuum of care
      • Making a plan for follow-up between visits
    4. Performs individual needs assessment, care plan design, documentation and implementation, and evaluation of outcomes. 
    5. Communicates a plan for healthcare needs between physician/office visits
    6. Coordinating needed patient education regarding specific health care skills and general disease concepts.
    7. Effective collaboration, communication, and coordination among all responsible  

parties of an individual member's multidisciplinary health care team, striving to eliminate fragmentation, duplication, or gaps in treatment plans.

  1. Works toward reduction of preventable hospital admissions, re-admissions,

excessive therapies, DME and other potentially preventable services. 

       i)   Communicating face-to-face in the office setting, by telephone, or by e-mail.

       j)   Assesses patient’s beliefs, wishes and values regarding advance directives and

            works with the care team to document and implement such wishes

       k)  Assesses patient’s understanding of personal exacerbation triggers.  Provides or

coordinates educational needs regarding the identification of triggers and actions to take when triggers are noted.

                    l)  Supports the Diabetic Education Program through patient and community education


  • Provides Coordination of Care across the care continuum including:
  1. Assists in the identification of "at risk" and "high risk" member populations needing care coordination
  2. Assisting as liaison with patients and their families to physicians, clinical staff, and community resources, and others by providing direct phone numbers and email access to the coach.  
  3. Acting as a liaison with hospitalized patients and the clinic.  Following up with patients by phone shortly after hospital discharge. 
  4.  Promotes coordination with consulting physicians (specialists) and other health care providers, including referral management to other CIN physicians, transfer of clinically relevant information needed by the healthcare team. 
  5. Proactively acting as patient advocate, responding to and working to resolve patient concerns
  6. Identifies potential barriers related to a patient's ability to effectively self-manage and works with patients (and caregiver) to resolve identified issues.  Works with member and families to optimize self-management skills through effective referral and coordination to appropriate community resources.
  • Actively participates in QI activities:
  1. Assessing and collaborating with clinic manager and director to identify practices or strategies to achieve clinic quality goals.
  2. Communicating and coordinating with the healthcare team in the development of tools for optimal patient outcomes and report findings.
  • Provide oversight of the disease registry database including:
    1. Assuring database is kept up to date.
    2. Identifying patients overdue for visits, labs, or referrals and arranging for follow-up services as appropriate.
    3. Identifying patients not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate.
    4. Creating patient, physician, and clinic level quality performance reports.
  • Provide oversight or conducts pre-visit chart review of patients including:
    1. Identification of all needed preventive health maintenance, immunizations, and chronic disease interventions.
    2. When standing orders allow it the interventions may be ordered or completed before the patient sees a provider.
    3. Fills out pre-visit forms or initiates office visits forms to communicate the review to the provider.
  • Able to assist practitioner in safe, effective delivery of patient care, as listed in the Clinic RN job description.


  • Licensed by State of Iowa as an RN
  • Clinic/Physician office, home care or public health experience preferred.   
  • Must have strong organizational (time management) skills, strong interpersonal skills and the ability to handle multiple priorities
  • Knowledge of and practical use of good business English, spelling, arithmetic, and the ability to communicate effectively using written and verbal skills.  Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word. 
  • Certification as Healthcare Coach or obtained within one year of hire.
  • Certification in case management (CCM), public health, and/or community health preferred. 
  • Ability to work autonomously within matrix environment without direct supervision or support
  • Basic Life Support (BLS) for the Healthcare Provider certified or obtained within three months of hire.
  • Proof of completion of Mandatory Reporter abuse training specific to population served within six months of hire.

Ability to demonstrate, understand, and apply our workplace values.  These are embedded in every position in the organization, and it is expected that every staff member will demonstrate these in every interaction, both internal and external.  These values include: Compassion Accountability Respect Excellence Service

Contact Information

Apply online at under "Careers" link at bottom of page.

Questions? Please contact Human Resources at  (515) 832-7711.

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