Provides education and coordination of care to patients who have been diagnosed with Diabetes. Develops care initiatives to assess and coordinate diabetes care management with the goal of achieving self-management skills related to Diabetes.
- Participates in the assessment of patient’s physical, emotional and social needs.
- In collaboration with the PCP develops and assumes responsibility for care planning.
- Assists patient with the development of their short and long term goals.
- Provides diabetes education, interactively and collaboratively with patient and care team.
- Tracks and ensures appropriate follow up care.
- Maintains communication with the patient, their family, and the care team to monitor and refine treatment plan.
- Participates in audits, medical record reviews, surveys and studies. Documents in the EMR (electronic medical record).
- Utilizes resources to assist with identification of diabetic patients who are in poor control of their diabetes. Identifies gaps in care by utilizing the diabetic registry.
- Attends and participates in staff meetings, care coordinator meetings, divisional meetings, and weekly case conferences. Serves as an active participant in the Diabetes recognition program.
- Assists patients in the development of annual goals and the identification of outcomes for continuous quality improvement.
- Maintains knowledge on new guidelines and medications.
- Performs other duties as required or assigned.
- Graduate from an accredited Nursing Program required.
- Associate Degree (ADN) prepared nurses with 5 years of clinical nursing experience and experience with diabetes education or counseling (glucose meter) required.
- Bachelor of Science Degree in Nursing (BSN) preferred.
- Strong organizational skills, excellent verbal, written and communication skills required.
- Must possess sound decision-making, time management and negotiating skills.
- Excellent computer skills are required.
- Demonstrated ability and interest in the care of individuals with chronic disease.
- CDE strongly preferred or must complete CDE certification program within 3 years in the position.
- Licensed Registered Nurse with NH eligibility.
- Basic Life Support (BLS) Certificate required.
