Diabetes Nurse Case Manager

Mass General Brigham•Somerville, MA

3d•Hybrid

About The Position

The Diabetes Nurse Case Manager serves as a bridge between patients, healthcare providers, and community resources. The role supports people living with diabetes by helping reduce diabetes-related hospital and emergency department visits, improve medication adherence, and build confidence in managing their condition. The nurse acts as an advocate, educator, and problem-solver, coordinating individualized care with patients, families, and their healthcare teams. This is a full-time hybrid position with an on-site presence at the Assembly Row, Somerville office roughly once per quarter. The schedule is Monday through Friday, generally 8:30 a.m. to 5:00 p.m. Eastern Time, with 40 scheduled hours per week. Remote workspace privacy and security requirements may be verified under organizational policy.

Requirements

Associate’s degree in Nursing.
Massachusetts Registered Nurse (RN) license.
Basic Life Support (BLS) certification.
Strong patient education and motivational interviewing skills.
Familiarity with care plan creation and documentation in an electronic medical record.
Ability to collaborate with diverse teams and populations.
Ability to listen attentively, understand others’ perspectives, ask appropriate questions, and avoid inappropriate interruptions.
Ability to use logic and reasoning to assess alternative solutions and approaches.
Ability to establish rapport and strong relationships with patients and staff.
Proficiency in Microsoft Office and industry-related software.
Ability to identify complex problems, review relevant information, evaluate options, and implement solutions.
Ability to maintain client and staff confidentiality.
Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.

Nice To Haves

Bachelor’s degree in Nursing.
At least 2–3 years of case management, utilization review, or discharge planning experience.
Experience in chronic disease management, ideally diabetes.
Pediatric experience.
CDCES certification.
Knowledge of healthcare and managed care.

Responsibilities

Assess members’ or patients’ medical, behavioral, and social health.
Define patient care goals by providing education, information, and direction to individuals and families.
Develop individualized diabetes management and care plans in collaboration with patients and their healthcare providers.
Modify care plans in response to patients’ conditions and responses.
Educate patients and families about medication use and lifestyle adjustments.
Conduct regular follow-ups by phone or telehealth and monitor medication adherence, nutrition, physical activity, and A1c.
Review challenging cases with medical directors as needed.
Maintain accurate, detailed reports and records.
Work with members after a recent hospitalization or emergency department visit to reduce readmission risk.
Collaborate with healthcare professionals, including behavioral health care managers, dietitians, social care managers, endocrinologists, and primary care providers.
Track patient progress using electronic health records and report outcomes to improve care strategies.