DIABETES CASE MANAGER/REGISTERED DIETITIAN-($36.06-$38.46)

Working collaboratively with the local Diabetes Program Team, other health professionals and community agencies, local RPMS[CE1]staff, Coordinating Center[CE2], IHS, and other grantees, the Diabetes Case Manger:

• Collaborates with the Diabetes Team to develop and implement a patient care plan that meets the IHS Diabetes Standards of Care and standards for medication dosage, and treating or monitoring treatment of CVD risk factors to recommended target levels. Evaluates educational and clinical outcomes and makes appropriate referrals. Monitor patient’s care plan and verifies that services are meeting client’s need; acts as client advocate when circumstances dictate.
• Conducts Cardiovascular Disease (CVD) Risk assessments and provides appropriate case management and referral to all persons with diabetes. Focus will be on reduction of CVD risk factors including obesity, hypertension, hyperlipidemia, etc.
• Obtains, documents, and tracks all clinical visits, specified laboratory values and dosages of medications prescribed and administered.
• Uses case management techniques to monitor education and clinical interventions for individual clients. Routinely monitors group data for performance improvement activities.
• Provides diabetes self-management training and education to individuals or groups on all aspects of diabetes care with special emphasis on CVD risk factors. Use reliable, science-based, and culturally-relevant education material for providing comprehensive diabetes self-management training.
• Documents on educational encounters; topics covered and evaluation of the patient’s understanding in the medical record.
• Develops a process to assist the patient with establishing a goal-oriented plan for behavior change and methods to evaluate outcomes.
• Uses teaching strategies that use a variety of approaches and methods which incorporate theories and concepts related to adult learning, readiness for change, empowerment, and motivational interviewing.
• Procures, organizes, evaluates, updates, and develops patient education materials for use by health are professionals, patients, and family members. This includes home monitoring equipment and supplies.
• Answer incoming calls on new cases and proceeds with a plan of action in collaboration with physicians, families and clients. Keeps clients and physicians informed and assists in coordinating care.
• Monitor and input case notes, to provide up-to-date and accurate information on status of case ensuring effective interdepartmental communication.
• Interpret policies for patients, physicians and staff to ensure understanding and adherence to policies.
• Assists other departments with interpretation of medical information, to ensure that consistent and accurate medical information is given.
• Assist RN Site Managers, Public Health Nurses, and Community Health Representatives in problem solving complex patient issues.
• Knowledge of and skill in using Windows based applications
• Broad knowledge of medical diagnosis and appropriate treatments.
• Able to manage and prioritize multiple tasks; ability to pay close attention to detail and multi-task.
• Excellent written and verbal skills; proven ability to communicate with patients, physicians, co-workers and business contacts in a courteous and professional manner.
• Possess problem solving interpersonal and phone etiquette skill; ability to use initiative in solving customer problems. Proven ability to maintain a positive and professional attitude.
• Data entry skills as required.
• Attend required meetings and training sessions, and participate in organizational performance improvement activities.
• Participate in clinic related health events in the communities served by the corporation. This may require working weekends and evenings, if needed.
• Other duties as assigned by the Director of Diabetes Program.