Chronic Care Manager (NP or PA Network Role)
About The Position
The Chronic Care Manager will provide individualized chronic disease education/management to individuals and groups according to the Standards of Practice for Certified Diabetes Care and Education Specialist. The manager will serve as a leader in chronic care with a focus on optimizing patient health, closing care gaps, and ensuring coordinated services for patients with chronic disease (with an emphasis on diabetes and hypertension). This position will provide DSMES and hypertension management in addition to other appointments in support of quality measures. These appointments will be patient-centered, respectful, and responsive to individual patient preferences, needs, and values. The Chronic Care Manager will work closely with the clinical team and other personnel to optimize patient care through various clinical initiatives. This work is carried out in support of the mission and goals of Ryan Network.
Requirements
- 6+ months of experience providing diabetes education and/or 15 contact hours within past year in diabetes and diabetes clinical and educational subjects.
- Ability to develop a collaborative, therapeutic alliance with individuals.
- Comfortable providing education to patients individually and in a group setting and working collaboratively with a team.
- Strong critical-thinking, problem-solving, and leadership skills.
- Excellent self-initiative and interpersonal communication abilities.
- Proficient in Microsoft Office (Outlook, Word, Excel).
- Organized and focused, able to thrive in a fast-paced clinical setting.
- Current, unrestricted licensed in the State of New York, either as Nurse Practitioner or Physician Assistant/Associate
- Board Certified or Eligible in Diabetes Care and Education (CDCES) or Advanced Diabetes Management
Nice To Haves
- eClinicalWorks experience and a talent for quality improvement process
- Bilingual: English/Spanish
Responsibilities
- Design and implement the chronic care program to ensure that patient assessment, education, referrals, and longitudinal management of patients is completed in accordance with departmental and NCQA standards.
- Maintain up to date knowledge of and act as expert in National Standards for DSMES to ensure program meets standards to maintain program recognition.
- Deliver individualized DSMES/T and hypertension education, including but not limited to the evaluation of each patient’s condition, degree of control, and educational needs, as well as collaboratively develop behavioral goals and clinical objectives.
- Evaluate effectiveness of educational services using behavioral goals and outcome measures.
- Provide educational interventions that utilize primarily interactive, collaborative, skill-based training methods, and maximize the use of interactive training methods.
- Optimize medication therapy in patients and monitor the patient’s response to therapy, including safety and effectiveness of medication.
- Connect patients with their PCP or other care and social service needs, such as Health Home staff and Licensed Clinical Social Workers.
- Oversee the implementation of an annual quality improvement project to measure DSMES program and to identify and address opportunities for improvement.
- Organize, develop, and facilitate diabetes/hypertension education group meetings.
- Conduct and coordinate outreach to high-risk patients to increase care engagement.
- Conduct annual wellness visits and other QI-focused appointments, as needed (ex: cervical cancer screenings, hospital discharge follow up appointments).
- Participate in the development of training materials for patients and providers.
- Support efforts to improve capture of hierarchical condition category (HCC) coding and risk adjustment factor (RAF) coding.
- Appraise his/her performance to identify areas of strength and areas for improvement and to develop a plan for improvement and growth.
- Participate in peer review process to evaluate performance of other professional instructional staff.
- Implement quality improvement (QI) programs to address gaps in care concerning diabetes, hypertension, and medication adherence.
- Projects and/or other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
