Overview

The Diabetes Care Coordinator is a licensed Registered Nurse (RN) responsible for providing comprehensive care coordination and chronic disease management services for patients living with diabetes and other associated chronic conditions. Working under the supervision of Population Health Care Coordination leadership, this role supports patients across home, primary care, specialty care, and community settings through in-person, telephonic, and virtual interactions.

 

The Diabetes Care Coordinator assesses, monitors, and collaborates with patients to develop individualized care plans that promote disease self-management, symptom stabilization, and improved health outcomes. Through health coaching, education, and ongoing support, the coordinator empowers patients to adopt healthy behaviors related to nutrition, physical activity, medication adherence, glucose management, and preventive care.

 

Partnering closely with patients, families, providers, and multidisciplinary care teams, this role helps patients establish and achieve meaningful health goals while addressing barriers to care, including social determinants of health. The Diabetes Care Coordinator supports population health initiatives by managing high-risk and rising-risk patient populations, closing care gaps, reducing avoidable emergency department visits and hospital readmissions, improving patient experience, and enhancing access to quality healthcare services.

 

Strong clinical judgment, communication, care coordination, and relationship-building skills are essential to effectively support patients throughout their continuum of care while contributing to improved quality outcomes, cost-effective care delivery, and organizational performance goals.

 

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.

EntryUSD $90,000.00/Yr. MaxUSD $90,000.00/Yr.