The Health Coach directly supports and promotes the care transitions and social support, and needs of patients' across the continuum of care. Also supports quality and improvement initiatives through targeted outreach to patients who are not meeting clinical goals. The position collaborates with providers, care managers, social workers, and others to facilitate seamless transitions of care, social support interventions, and patient engagement to close care gaps with the goals of assuring superior patient experience and quality outcomes. Identifies high-risk patients, assesses clinical and psychosocial needs, makes referrals to ancillary providers (disease management, palliative care, community organizations, pharmacy, social work, non-clinical services) and develops care plan in coordination with PCP. Engages patients to be active in self-care and personal responsibility.