Chronic Care Manager (Nurse Practitioner OR Physician Assistant)

Description

Position Overview:

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, which 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.  

Essential Functions:

• 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 in collaboration with other health care providers.
• 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.

Qualifications

Minimum Experience and Skills Required:

• 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.

Education, Licenses and/or Certification Required:

• 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

Preferred Qualifications:

• eClinicalWorks experience and a talent for quality improvement process
• Bilingual: English/Spanish

Competencies Required:

Customer Service

• Displays professional, courteous and respectful attitude in dealing with patients.
• Commits to exceeding expectations of the patient.
• Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patient served.

Cooperation/Teamwork

• Works well with others.
• Contributes input to improve outcomes.
• Asks others for opinions and feedback; provides feedback in a tactful respectful way.

Minimal Training Time:

180-day introductory period.

Working Conditions:

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit, talk and hear.

Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The work is primarily in a mental health and/or general primary care setting which include the unpredictability in behaviors of individuals and acute and chronic infectious diseases which may be contagious.  Adequate preparation and precaution is necessary. 

Disclaimer

The duties listed above are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment to the position.  This position may be required to perform other duties.  If such work becomes a permanent and regular part of the job, a new description will be prepared. 

Equal Opportunity Employer

Ryan Health is an Equal Opportunity /Affirmative Action Employer and does not discriminate because of age, color, disability, ethnicity, marital or family status, national origin, race, religion, sex, sexual orientation, military veteran status, or any other characteristic protected by law.  We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.

Salary : $130,000 - $135,000