Description: The Chronic Condition Care Manager will support the Health Care Teams and Primary Care Practitioners in the medical office in order to drive quality around chronic condition management. These conditions include, but are not limited to, diabetes and hypertension. The Chronic Condition Care Manager serves members in a compassionate, personalized and supportive manner while performing clinical assessments, education and care coordination on a one-on-one and group basis. The Chronic Condition Care Manager completes assessments, creates customized care plans in collaboration with the PCP, member and provides comprehensive chronic condition education, identifies, communicates, and rectifies suboptimal care, and optimizes clinical outcomes. The Chronic Condition Care Manager supports the development of standard operating procedures, patient care guidelines, educational initiatives, care gaps closure. Assists the member in gaining the knowledge, skills, attitude, and self-awareness necessary to effectively manage his/her s chronic condition as evidenced by improvement in targeted quality metrics (A1C, LDL, BP, etc.) to help prevent/minimize clinical complications.
- Educates member on topics related to their chronic condition and the disease process; including all aspects of effective self-management (medication, diet and nutritional monitoring; foot care, prevention and care of complications; recommended screenings, blood glucose monitoring and the techniques of self monitoring and insulin injections).
- Utilizes treat to target recommendations per protocol for cardiovascular related medications and provides clinical patient education, support and follow-up to members to ensure effective self-management.
- Assesses, monitors and implements treatment plans for patients at various stages of the disease. Makes recommendations to the PCP and patient/family for adjustments in the plan of care as required.
- Identifies and helps close care gaps related to A1C, lipid panel, blood pressure, laboratory tests, PCP visits, eye exams, foot exams, flu shots, etc.
- Conducts outreach via letter, secure e-mail, and telephone to targeted members.
- Helps coordinate next care steps including assistance with scheduling appointments/classes with other resources within KP such as Diabetes Class, registered dietitian, clinical pharmacy specialists, behavioral health, nurse visits and PCP as needed.
- Assesses resources available for education in the module (DVDs, handouts, etc) and recommends the current and most appropriate resources to use. Teaches classes, participates in pilot efforts to improve care as needed.
- Provides in-services/support as a nursing/ clinical practice subject matter expert as needed.
- Maintains and updates professional knowledge and skills in cardiovascular disease management.
- Hours, days and work location within the Georgia region may be adjusted to the needs of the department or members.
- May perform other duties as assigned.
- Five (5) years of nursing experience as a registered nurse.
- An equivalent combination of post-graduate diabetes training and experience may be considered.
- Bachelor's degree of science in nursing.
License, Certification, Registration
- Current licensure as a Registered Professional Nurse in the State of Georgia or able to obtain prior to date of hire.
- Excellent diabetes and cardiovascular disease and chronic health conditions clinical knowledge base.
- Knowledge of adult learning principles.
- Able to assess and interpret relevant lab results.
- Ability to work under protocol to initiate and adjust insulin as needed.
- Ability to work collaboratively with a variety of health care professionals.
- Basic knowledge of Microsoft Office Suite (Excel, Work, PowerPoint) essential.
- Bilingual preferred.
- Current Certified Diabetes Educator (CDE).