PRIMARY ROLE OBJECTIVE:
Works with the Quality Team to manage quality, comprehensive care to patients with a diagnosis of diabetes and/or other chronic conditions. Empowers patients to self-manage their health conditions by utilizing a team-based care approach, reduce the occurrence of preventable complications, and set up successful visits with primary care providers. Actively reviews performance measures related to diabetes and associated chronic conditions to create in-clinic workflows that meet quality measures related to diabetes.
SUPERVISORY RESPONSIBILITIES:
None
MAIN DUTIES & RESPONSIBILITIES:
Communicates health information to patients, support staff, and team members
Demonstrates ability to utilize FHC endorsed population health data and tools to coordinate and address quality of care gaps for FHC patients with diabetes proactively.
Coordinate care with medical team, lab, call center and patients to assess needs, identify barriers and coordinate plan of care and communication among multiple providers and team members.
Relays appropriate information between patient and care team by documenting in EHR and Project Management tools.
Integrate Quality Program identified patients into routine care management regarding care plans, by phone and/or video conference.
Act as education and support resource on diabetes population health for patients and FHC care teams including other care managers.
Assist in placing orders and screenings for patients with diabetes to streamline and improve quality of care in patients with diabetes - inclusive of HbA1c testing, lipid testing, retinal and foot screening, and referrals to community-based resources and nurse visits as needed
KNOWLEDGE, SKILLS & ABILITIES:
Ability to prepare basic correspondence and simple reports in Microsoft Word, Basic Excel Spreadsheet, Google Docs, and Google Sheets.
Ability to create, send and manage email in Gmail
Ability to access web-based applications and programs of others
Fully functional in use of the Electronic Health Records (Athena EHR).
Requires more advanced organizational skills, in order to organize projects or the work of others.
EDUCATION & EXPERIENCE:
Job duties require knowledge and training in the field of nursing typically acquired through a formal Associates degree or trade school program in nursing.
ELIGIBILITY QUALIFICATIONS:
Must reside in Washington State and have Registered Nurse licensure with the State of Washington
OTHER DUTIES CLAUSE:
This job description is a summary only and not meant to be a comprehensive list of all the duties and responsibilities for the job. Changes to current duties and new duties and responsibilities can be assigned at any time without notice. Performance will be evaluated in relation to this job description to include any potential changes or addition to duties as assigned.