Responsibilities

• Coordinate and manage care for patients with diabetes and other chronic conditions using established clinical protocols and evidence-based disease management practices.
• Assess patient health status, identify care needs, and develop individualized, patient-centered care plans in collaboration with providers and the multidisciplinary care team.
• Promote patient self-management through diabetes education, health coaching, goal setting, motivational support, and teach-back learning techniques.
• Encourage healthy lifestyle behaviors, including medication adherence, nutrition management, physical activity, glucose monitoring, and preventive care practices.
• Monitor patient progress and adherence to treatment plans, identify barriers to achieving health goals, and implement interventions to improve outcomes.
• Provide ongoing outreach and support to high-risk and rising-risk patients utilizing population health data, payer reports, claims data, risk stratification tools, and clinical registries.
• Coordinate healthcare services across primary care, specialty care, hospital, home, and community settings to ensure seamless continuity of care.
• Facilitate referrals and care transitions, ensuring timely completion of diagnostic testing, specialist consultations, and recommended services.
• Collaborate with Community Health Workers (CHWs) and community-based organizations to address social determinants of health, reduce barriers to care, and connect patients with appropriate resources.
• Serve as a patient advocate by assisting individuals and families in navigating healthcare systems, community services, advanced care planning, and healthcare proxy completion.
• Identify behavioral health needs and coordinate referrals to appropriate mental health and support services.
• Review and evaluate patient care plans regularly, revising interventions based on clinical outcomes, patient needs, and provider recommendations.
• Partner with providers and practice teams to proactively address medical, behavioral health, and care coordination needs through ongoing communication and follow-up.
• Reduce avoidable emergency department visits, hospital admissions, and readmissions through early intervention, patient engagement, and comprehensive care management.
• Assist with closing preventive, quality, and chronic disease care gaps to improve patient outcomes and quality performance measures.
• Participate in multidisciplinary team meetings, patient huddles, and case reviews to support coordinated patient care and identify opportunities for improvement.
• Review high-cost and high-utilization patient populations to identify drivers of healthcare utilization and recommend strategies to improve outcomes and reduce costs.
• Support advance care planning initiatives, including discussions regarding advance directives and appropriate referrals to palliative or hospice care services when indicated.
• Collaborate with Population Health leadership to implement quality improvement and process improvement initiatives that enhance care coordination effectiveness and patient outcomes.
• Maintain accurate and timely documentation in accordance with organizational policies, regulatory requirements, and care coordination standards.
• Demonstrate strong communication, collaboration, relationship-building, and customer service skills with patients, families, providers, and community partners.
• Maintain knowledge of current diabetes care guidelines, population health strategies, and chronic disease management best practices through ongoing professional development.
• Comply with all organizational policies, procedures, regulatory requirements, and professional standards.
• Perform other duties as assigned in support of population health and care coordination objectives.

Qualifications

• Minimum of two (2) years of work in the healthcare field
• BLS (CPR & AED) certification issued by the American Heart Association (AHA)
• Previous nursing experience in a Clinic/Outpatient environment
• Previous work using Electronic Health Records (EMR)
• Bilingual English/Spanish language skills are a definite plus
• Proficiency with MS Office Suite (Word, Excel, and Outlook)

Credentials

• Active RN License in Delaware or compact state

Education

• Graduate of an accredited school of nursing

Other Information

The salary for this position is established through grant funding and has been approved as part of the program budget. As a result, the posted salary of $90,000 is fixed and cannot be negotiated.

Entry

USD $90,000.00/Yr.

Max

USD $90,000.00/Yr.