Care Manager -Diabetes Job Ann Arbor area,Michigan USA,Nursing

POSITION DESCRIPTION:

The Care Manager I-Diabetes is an integral member of the interdisciplinary team to provide education to the patients with diabetes. Provides individual and group patient education in line with the American Association of Diabetes Educators and Michigan Department of Community Health standards and guidelines. Meets with patients and caregivers to assess diabetes-related knowledge and self-care habits, providing appropriate diabetes education. Works in collaboration with dietitians, pharmacists and physicians in order to provide overall diabetic care and meet the patient needs for additional services.

ESSENTIAL JOB FUNCTIONS:

Assesses patient’s diabetic status by reviewing medical records, labs results, blood glucose monitoring trends, various clinical assessments and patient consultation. Assesses patient’s diabetes knowledge and self-care behaviors, evaluating ability/readiness to learn and make changes.

Maintains and evaluates patient education material related to diabetes using evidence based practice. Develops new materials as needed.

Develops and conducts group visits that provide education, resources and techniques for diabetic patients and their caregivers to manage their diabetes.

Collaborates with members of the health care team and patient to ensure the delivery of quality, efficient, patient centered, and cost effective healthcare services.

Assists patients who are at risk for developing chronic conditions to minimize these risks by providing self-management support and patient education; empowers patients to manage their health

Provides targeted interventions to avoid hospitalization and emergency room visits; in specialty population, the care manager ensures proper triaging of the patient and appropriate delivery of care in accordance with established protocols.

Assesses, plans, implements, monitors and evaluates delivery of individualized patient care with the goal of optimizing the patient’s health status.

Maintains certification of specific insulin infusion pumps and CGM as needed.

Performs and educates patients on foot exams.

Participates in the outreach and engagement of enrolled patients that are hospitalized to assist with the transition of care and provides support and education to avoid further readmissions.

Coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resources outcomes.

Maintains the ability to utilize guidelines and standards of care for management of chronic diseases.

Makes “cold calls” and engages patients into the program effectively.

Clinical responsibilities include:

Coordinates and provides patient education for common patient populations within the office.

Designs individual plan of care for patients based on evidence-based guidelines.

Fosters a team approach by collaborating/referring patients to supporting members of the care team (RD, CDE, pharm, panel manager etc.) and ensures coordination of services.

Assesses health behavior and disease-specific risks; identifies a plan of action for patients.

Assures clinical compliance with follow through utilizing reminders, follow-up calls, patient and office education.

Refers selected patients to determined community resources and coordinate with these resources.

Provides patient-specific feedback to providers and clinical team. Provides face-to-face, virtual, and telephone interactions with patient population.

Utilizes relevant computer information support including the EMR and any other care management and/or clinical IS systems needed to complete the tasks of clinical care and performance reporting.

Directly enters medication, laboratory, and orders into the EMR records per standard protocols and professional guidelines.

Works with patients and providers to customize services that will best meet the needs of the patient and work within their benefits.

Researches and facilitates services for patients outside of their benefits while utilizing community services and resources.

Assists in…


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