Diabetes Care Coordinator, Quality Assurance

The Diabetes Care Coordinator provides comprehensive case management services to Disease Management patients, which includes patients with Diabetes. The Diabetic Care Coordinator acts as an educator, care coordinator, resource and advocate for all patients at JWCH. The Diabetes Care Coordinator will assess and develop a care plan in collaboration with the care team (Primary Care Provider, patient, and any other essential members of the clinic team) with providing health education services. The Diabetes Care Coordinator is responsible for developing a positive relationship with patients and assisting the patient through the process of actively working towards better health by providing support, encouragement, and education.

Overview of Responsibilities:

1. Lead efforts in collaborative goal setting and reviewing goals. 
2. Patient will be informed what HgBa1c is, and HgBa1c goals. 
3. Conduct outreach medication review/reconciliation
4. Educate the patient during visits.  
5. Collaborate with the patient and family, set goals for diet and exercise. 

Principal Responsibilities:

1. Coordination of Care
   • Using the pre-visits huddle report, the Diabetes Care Coordinator prepares charts for all scheduled diabetic patients prior to patient arrival, and designates the key registry measures or indicators that need to be addressed at each visit.
   • Contacts all "No Show" diabetic patients by phone or mail to reschedule missed appointments. Assign voicemail numbers to registry patients without phone numbers. 
   • Participate in chronic diseases meetings with clinical supervisors and peers to assist in problem solving related to clients and to ensure that professional guidance and high-quality case management services are being provided. 
   • Identifies clinical measures that are out of range and appropriately refers to team members. Measures that maybe out of range include: hemoglobin A1c, blood glucose, blood pressure, weight, height, waist circumference, body mass index, and ketone testing. 

1. Basics of Diabetes Self-Care 
   • Discuss, in basic healthcare language, the diagnosis and instructions given by the healthcare provider.
   • Utilizing JWCH’s approved Point of Care testing workflow, Point of Care testing is completed for all diabetic patients. 
   • Follows workplace-specific clinical practice protocols and guidelines applicable to diabetes management (i.e. Care Guidelines).
   • Assists person in obtaining accurate and appropriate diabetes resources from diabetes toolkit. 
2. Outreach and Education 
   • Utilizing JWCH’s approved outreach workflow and protocol, the diabetes Care Coordinator conducts a minimum of 60 outreach calls per week, to all diabetic patients who are overdue for all preventative exam services (A1C test, diabetic retinal exam, and foot exam). 
   • Utilizing Next-Gen’s ABC self-management template, the Diabetic CM will conduct case management services to include intake and assessment, clinician treatment plan implementation, monitoring and follow-up.
   • Meets with registry patients at each scheduled visit to initiate and/or update self-management goals.
   • Monitors and maintains logs for patients with A1C greater than 9, to include contacting all patients and ensuring that they have a follow-up appointment.  Clinic administrators are responsible for providing this report. 
   • Collaborates with person to develop behavior goals in alignment with the treatment plan; assesses progress toward goal achievement and modifies the education interventions accordingly or seeks assistance with barrier resolution/other identified issues from appropriate team member.
3. Cultural Competency Across Lifespan: 
   • Provides education in a culturally-appropriate manner.
   • Works with healthcare team to identify and overcome cultural barriers to self-care or behavior change. 
   • Assists person in obtaining accurate and appropriate community resources.
   • Acts as the patient liaison for the care team.
4. Self-Management and Education: 
   • Diabetes Care Coordinator is responsible for working with the patient and setting self-management goals for: Eating, Monitoring, and Medications
   • Reducing Risk: Reinforces the need for basic preventative and risk reduction measures, e.g., foot exams, eye exams, dental exams, lab measurements, smoking cessation, flu vaccines, and immunizations
5. Diabetes Group Classes:
   • If employee is certified in the Diabetes Education Empowerment Program curriculum, employee is required to lead two 6-week sessions for diabetic patients at JWCH a year. 
   • If employee is not certified then they must refer patient to an educator that is. 
6. Other Duties: 
   • Prepares and reports data as needed by Senior Leadership and enters necessary data for reporting and other projects activity reports as assigned for submission to funding source(s), CPCA or JWCH Committee.
   • Participates in agency and community meetings pertaining to the needs of patients and issues related to chronic disease management.
   • Performs other duties as assigned.

Requirements:

1. Three (3) years of experience working with Diabetic patients.
2. Bachelor's degree in health-related field or equivalent experience as a medical assistant or licensed vocational nurse is preferred. 
3. Data entry skill required. Experience with Microsoft Word, Excel and Power Point.
4. Willing and able to work well with low income individuals and residents.
5. Bilingual (English/Spanish) ability (preferred). 
6. Experience with electronic medical records is highly desired.
7. Basic medical terminology knowledge.
8. Strong interpersonal skills, energetic, passionate, and innovative.
9. Demonstrates ability and desire to relate to and work with people of all ages, social and ethnic backgrounds and to convey a sense of confidence and trust to all patients.
10. Demonstrated ability to work independently and as a team member improving delivery of care to persons with chronic diseases.
11. Demonstrates sound problem-solving skills.
12. Confident to communicate and outreach to other community health care organizations and personnel.

*All JWCH, Wesley Health Centers workforce members are recommended to be fully vaccinated against COVID-19.

Employee Benefits:

At JWCH Institute, Inc., we believe in taking care of those who take care of others. If you work 30 hours per week, you’ll enjoy competitive pay and a benefits package that includes:

• A monthly allowance for medical, dental, and vision premiums
• Paid time off (vacation, sick leave) and 13 paid holidays
• 401(k) Safe Harbor Profit Sharing plan
• Mileage reimbursement
• Short- and long-term disability plans, life insurance, and more!

Become part of a team where your work matters. Apply today and help us change lives, one patient at a time.

JWCH Institute, Inc  Wesley Health Centers is an Equal Opportunity Employer!