Diabetes Community Care Coordinator

Summary

The Diabetes Community Care Coordinator (DCCC) will provide individualized diabetes self-management education within their documented competency according to the current American Diabetes Association Standards of Care. The DCCC is expected to exercise a high degree of initiative and judgement in providing patient education and follow-up as needed. Coordinates patient care with necessary staff. Bilingual English/Spanish required. Starting wage is $17 - $19 DOE.

The wage will increase to $19 - $20 DOE once the candidate completes the in-house Diabetes Educator Certification. Employees can earn up to $520 on the quarterly bonus.

• Participate in the delivery of team-based care in assigned clinic(s).
• Provide comprehensive and follow-up education through an interactive educational style for diabetes education program participants.
• Evaluate and document attainment of educational objectives.
• Collaborate with team members for appropriate tracking, follow-up of referrals, and scheduling.
• Follow FHS policies and procedures in documenting in the EHR.
• Collect, manage, and review data and develop reports incorporated into the Quality Improvement Programs and as requested for ADA recognition.
• Work collaboratively with the clinical team, including O&E, Care Managers, and BHCs.
• Participate in ongoing trainings, learning sessions, conference calls, webinars, and other professional development opportunities.
• Utilize registries, electronic reports, and review of provider schedules to proactively assess and coordinate preventive screening, care coordination, and communication; document measures and interventions via EHR; and assure that care is patient centered.
• Use clinical, evidenced-based care guidelines to monitor patient health status and need for services. Coordinate high-risk patient risk reduction, hospital and ER utilization, and improvement of patient outcomes.
• Use IRIS and Idaho Health Data Exchange to track immunization status and recall for immunizations.
• Follow up with patients as requested by provider.
• Assist in education, assistance, support for patients and families, and care coordination with outside providers and community resources.
• Assess patients’ readiness to change, monitor compliance with plan of care; and problem-solve barriers related to the health care system, and financial and psychosocial barriers.
• Utilize behavioral strategies to assist patients in adopting health behaviors, improving self-care, and managing chronic disease.
• Assist Outreach and Enrollment staff with patient’s eligibility requirements for Medicaid, SSI, etc., and with coordination of enrollment with service agencies.
• Make reminder calls for patient visits, to include but not limited to the guidelines set forth by FHS for PCMH and Meaningful Use.
• Participate in FHS meetings and committees as assigned.
• Assist in planning of new strategies for outreach.
• Participate in outreach community events as needed.
• Ability to travel to outreach and other FHS clinics.
• Perform other duties as assigned.

• Excellent organizational skills and strong written and verbal communication skills.
• Strong computer skills. EHR experience preferred.
• Ability to build and maintain effective partnerships internally and externally with an awareness of community resources.
• Ability to work with patient/client groups and/or experience in membership organizations.
• Ability to work with minimal supervision and maximum accountability to problem-solve and work independently and collaboratively as a member of a team.
• A professional demeanor, and a pleasant manner in telephone and personal contacts.
• Analytical skills with the ability to manage and prioritize multiple tasks.

• High school diploma or GED equivalent.
• Evidence of previous experience or training in: diabetes, chronic disease, health and wellness, healthcare, community health, community support, and/or education methods as evidenced by a resume or certificate.
• Excellent verbal, written, and presentation skills.
• Possess good people skills to work with patients, clinical staff, and specialists.
• Spanish Literacy (preferred).
• Medical Assistant, Diet Technician…