Works with the PCP and clinic staff to identify patients with high risk diagnoses such as CHF, IHD, COPD/asthma and diabetes and ensures clinical guidelines are being followed Contacts and performs initial interviews with patients who are in need of health coaching programs Conducts Chronic Care Model visits and reviews the patient’s informal and formal support systems, focusing on what patients want to improve and educating them about their chronic disease Provide necessary coaching to reduce or eliminate behaviors that are considered high-risk Identify the required goals that each patient must fulfill and advice feasible options for achieving goal Ensure that patients are made aware of health issues, concerns and the way in which one could combat them Must raise awareness about the different available exercises, weight loss programs and other dietary requirements necessary for a healthy lifestyle Utilizes appropriate motivational interviewing techniques necessary for coaching and assisting the patient to complete a self-management goal/action plan Must be able to provide a chart of habits and lifestyle changes that are imperative for the improvement of the concerned patient’s health Enters timely and accurate data into the electronic medical record to communicate patient needs and to ensure complete documentation of patient visits and phone calls. Tracks self-management goal outcomes and documents in electronic medical record Maintains current knowledge regarding CHF, IHD, COPD/asthma and diabetes as well as related treatments and complex medications Assists, initiates referrals, and coordinates transitions of car regarding hospitalization follow-up, palliative care, hospice, etc. Establishes a trusting relationship with identified patients, caregivers, clinic staff members and physicians Attends educational offerings to keep abreast of change and complies with licensing requirements, ensures all patient educational materials are up-to-date, and maintains knowledge of specialty and ancillary provider contract contents, to include exclusions and contract terms Conducts clinic one-on-one visits with Disease Management Chronic Care Program participants, utilizing the Chronic Care Model, to assess patient needs for DME, home health, value-added services and any other necessary resources.  Communicates these needs to the appropriate person (i.e. Social Worker, clinic staff, etc.) or addresses them per process Collaborates with the nurse manager to recommend policies, procedures and standards which affect the care of the patient with high-risk chronic disease diagnoses such as CHF, IHD, COPD/asthma and diabetes Performs all other related duties as assigned. i.e. IV Insertion with hydration fluid administration, wound care, dressing changes, suture removal, insertion and removal of urinary catheters, and etc.