RN Care Management Diabetes Educator, Full time remote

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Provides specialized nursing care for patients and populations with diabetes through clinical management of a patient caseload, education, use of technology, protocol-supported medication adjustments, interprofessional collaboration, and application of research/best practices. Supports achievement of patient and population-targeted outcomes, advising on diabetes program development as appropriate. Elevates skills and knowledge of internal teammates and departments who also provide care to patients with diabetes.

 

MAJOR RESPONSIBILITIES:

Outreaches to and manages a caseload of patients identified through referrals/consults and/or population stratification algorithms per department expectations. Interacts with patients primarily through telephonic and/or virtual means. In-person care opportunities are addressed on a case-by-case basis.

 

Executes nursing process that starts with assessing whole person needs which influence patient outcomes, including (but not limited to):

social determinants of health, medication use/adherence, self-management knowledge/skills/abilities, patient-centered goals, and physical symptoms. Utilizes clinical expertise, American Diabetes Association standards, and evidence-based practice to identify and analyze complex problems in nursing care of individuals and populations with diabetes; makes recommendations, evaluates alternative solutions, and follows up with appropriate health care personnel and patients.

May adjust diabetes medications from physician-prescribed starting dosage per protocol (with appropriate training/competence) and evaluate effects. Advocates for patients and professionally communicates with leaders and interprofessional teams to create a patient-centered plan of care to support optimal patient and population well-being.

Uses approved technology to interact with patients with diabetes, their equipment, and related data. Technology utilized includes (but is not limited to): a softphone, glucometer, continuous glucose monitor, insulin pump, glucometer data platforms, remote patient monitoring, and video visit software. Executes workflows within the electronic medical record and related patient-care platforms per department standards. Documents according to department and professional standards set by the American Diabetes Association.

 

Communicates and collaborates with interprofessional, cross-continuum teams including the primary care team, endocrinologist, hospital care team, care managers, inpatient case managers, pharmacists, social workers, community health workers, and other care partners to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Understands value-based care delivery concepts and related contractual obligations quality performance metrics, and cost-savings objectives.

 

Connects process and outcomes data with personal and department successes and opportunities. Functions as an expert resource within the department to support continuous learning, high reliability, quality improvement, patient engagement, maximization of technology, and internal teammate skills and knowledge around caring for patients and populations with diabetes. Acts as a representative of and liaison to Ambulatory Care Management.

Engages in professional interactions that foster collaboration and awareness of care and services within Ambulatory Care Management. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirements relative to his/her age-specific needs, and to provide the care needed as described in the department’s policies and procedures. Age-specific information is developed further in the departmental job standards.

 

LICENSE/REGISTRATION/CERTIFICATION:

A registered Nurse license is issued by the state in which the team member practices, and a Registered Certified Diabetes Educator (C.D.E.) by the American Association of Diabetes Educators or eligibility to take the Board exam is required. Must obtain C.D.E within 6 months of start date if not certified at the time of hire. Assumes responsibility for maintaining certification. EDUCATION: Bachelor’s Degree in Nursing EXPERIENCE: Requires 5 years in patient care, focusing on chronic illness working as a certified diabetes educator.

 

MINIMUM KNOWLEDGE, SKILLS, AND ABILITIES

(KSA) Knowledgeable in best practice standards for diabetes care set by professional organizations, such as the American Diabetes Association, or established or emerging evidence. Must be self-directed with the ability to work well independently and within a team environment while recognizing and meeting the individual needs of external and internal partners/customers. Ability to demonstrate excellent oral, written, and interpersonal skills. Ability to demonstrate critical thinking, problem solving and excellent organizational skills.

Ability to work productively and effectively in a complex environment that includes multiple changing priorities. Demonstrated ability to work well with physicians and other healthcare professionals directly and positively. Proficient computer/Microsoft suite skills and previous Epic EMR experience. Ability to handle multiple responsibilities.

 

PHYSICAL REQUIREMENTS AND WORKING CONDITIONS:

Remote work is expected. Office set-up and internet access must meet System and department remote work guidelines. Position may require travel between clinic sites so there may be exposure to road and weather conditions. Manual dexterity is required for operate the computer and calculator. Visual acuity required to facilitate review of written documents/computer screens, medical records, and to record information accurately.

 

Clear oral communication and hearing acuity required for receiving instructions and conversing on standard telephone. Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone. Exposed to normal office environment; including usual hazards related to operating electrical equipment. Operates all equipment necessary to perform the job. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent.

Incumbent may be required to perform other related duties. Advocate Aurora Health is one of the 10th largest not-for-profit, integrated health systems in the U.S. with nearly 3 million patients served at more than 500 sites of care in Illinois and Wisconsin, including 28 hospitals. We’re redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in a variety of specialties. Advocate Aurora Health is one of the 10th largest not-for-profit, integrated health systems in the U.S.

with nearly 3 million patients served at more than 500 sites of care in Illinois and Wisconsin, including 28 hospitals. We’re redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in a variety of specialties.

 

This is Transformation One shared purpose brought us together.

Now, as one of the 10 largest not-for-profit, integrated health systems in the United States, our combined strength and stability drives us forward. Starting with You Caring for nearly 3 million people has inspired a transformation. One in which the patient’s experience guides our vision and empowers us to offer new possibilities in our communities. Reshaping Access What is access? It’s offering more sites of care than any other health system in the Midwest.

But there’s a new frontier. Access is exploring the latest technologies to deliver care to patients exactly where they are and exactly when they need it Inspiring Professionals With our dynamically inclusive workforce and strong connections to the places where we live and work, we’ll touch more lives and contribute to stronger and more vibrant communities.

Transforming Care We’re redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in: Cardiovascular Care Neurosciences Gynecology Oncology Pediatrics Primary Care Neurology Geriatrics Trauma Care

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