Care Manager -Diabetes

Care Manager -Diabetes

POSITION DESCRIPTION :

The Care Manager I-Diabetes is an integral member of the interdisciplinary team to provide education to the patients with diabetes. Provides individual and group patient education in line with the American Association of Diabetes Educators and Michigan Department of Community Health standards and guidelines. Meets with patients and caregivers to assess diabetes-related knowledge and self-care habits, providing appropriate diabetes education. Works in collaboration with dietitians, pharmacists and physicians in order to provide overall diabetic care and meet the patient needs for additional services.

ESSENTIAL JOB FUNCTIONS :

• Assesses patient’s diabetic status by reviewing medical records, labs results, blood glucose monitoring trends, various clinical assessments and patient consultation. Assesses patient’s diabetes knowledge and self-care behaviors, evaluating ability / readiness to learn and make changes.
• Maintains and evaluates patient education material related to diabetes using evidence based practice. Develops new materials as needed.
• Develops and conducts group visits that provide education, resources and techniques for diabetic patients and their caregivers to manage their diabetes.
• Collaborates with members of the health care team and patient to ensure the delivery of quality, efficient, patient centered, and cost effective healthcare services.
• Assists patients who are at risk for developing chronic conditions to minimize these risks by providing self-management support and patient education; empowers patients to manage their health
• Provides targeted interventions to avoid hospitalization and emergency room visits; in specialty population, the care manager ensures proper triaging of the patient and appropriate delivery of care in accordance with established protocols.
• Assesses, plans, implements, monitors and evaluates delivery of individualized patient care with the goal of optimizing the patient’s health status.
• Maintains certification of specific insulin infusion pumps and CGM as needed.
• Performs and educates patients on foot exams.
• Participates in the outreach and engagement of enrolled patients that are hospitalized to assist with the transition of care and provides support and education to avoid further readmissions.
• Coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resources outcomes.
• Maintains the ability to utilize guidelines and standards of care for management of chronic diseases.
• Makes “cold calls” and engages patients into the program effectively.

Clinical responsibilities include :

ORGANIZATIONAL EXPECTATIONS :

MEASURED BY :

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position. Care Management Metrics including productivity and ACP education and completion, and others defined by program.

ESSENTIAL QUALIFICATIONS :

EDUCATION : Bachelor of Science degree in Nursing (BSN) or Associates Degree in Nursing with extensive nursing experience.

CREDENTIALS / LICENSURE : Valid, unrestricted RN license in the State of Michigan; valid CPR certification. Certified Diabetes Care and Education Specialist (CDCES) Certification required.

MINIMUM EXPERIENCE : 3-5 years of experience working with diabetic patients in primary care / ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical, within the past five years. Care management experience preferred. Experience as participant in continuous quality improvement preferred.

POSITION REQUIREMENTS (ABILITIES & SKILLS) :

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