Trinity Health SJHSYR_Health Coach_3025-1 in Syracuse, New York


The Health Coach, RN will identify and carry a caseload of patients with chronic or complex diseases and/or high utilization patterns; independently provide support to patients in transitioning across the continuum of care by providing nurse assessment and care planning, education, coordination and consultation; and track individual and population based outcomes. This position will be centrally located in the Syracuse area. This is your opportunity to build relationships with your patients and families, be a true caregiver, and utilize your expert experience in assisting with your patients' needs.



  • Identify high-risk patients through a review of population-based and individual patient information.
  • Provide a baseline patient assessment of patient activation and knowledge, wellness, health behaviors, clinical condition and medical utilization.

Care Planning:

  • Develop a patient care plan to include patient goal, education targets, social supports needed, and recommendations for the clinical care team.


  • Provide individual and group education and coaching that activates patients to enable them to make knowledgeable health decisions and participate more fully in their care.


  • Identify transitional care gaps and coach patients to access appropriate services.
  • Identify needed community and medical services to support patients' goals and coach patients to access them.


  • Identify clinical care improvements that could support patients in achieving activation and health goals.
  • At the physician's direction, work to modify clinical care plans to support patients in achieving activation and health goals.
  • Facilitate modification to clinical care plans through the clinical care team.
  • Support patient navigators by providing clinical advice and patient communication, where appropriate.

Outcomes Assessment and Tracking:

  • Maintain patient registries to identify patients at risk and track outcomes.
  • Track changes in patient activation, health behaviors and clinical outcomes and, identify and implement appropriate interventions.
  • Provide population-based summaries of outcomes.


Bachelor's prepared in nursing or other clinical field, or clinician with Bachelor's or Master's in education, health services or related field. Minimum of two years of experience in primary care, patient coaching or outpatient case management, etc. Candidates must demonstrate at least one year in providing patient/family education. Training in the Care Transitions Intervention or Transitional Care models a plus. Experience in collecting and utilizing population-based data to identify patients and prioritize interventions preferred.

Successful candidates will have excellent interpersonal skills to work effectively with patients and the members of the clinical care team. They will take the initiative to ensure clinical care and related support services are made available to patients. They will also have the ability to think critically and creatively about what is needed to improve patient activation and health improvement. Successful candidates must be excellent educators and be able to empower patients. Successful candidates will need to be able to function independently in a fast-paced environment, prioritizing responsibilities and multitask.



Office/Clinical setting. Exposure Class 1.


Light work: standing, walking, sitting and lifting.


Job Number: 00117004

Location: Syracuse, NY

Organization Name: St. Joseph's Health


Employment Type: Full time

Hours: 40