Chronic Disease Management Nurse

Job Title: Chronic Disease Management Nurse

Department: Rural Health Clinic

Reports To: Medical Director

Job Summary: The Chronic Disease Management Nurse plays a pivotal role in enhancing the quality of care for patients with chronic conditions. This position is responsible for coordinating and managing the care of patients enrolled in the Chronic Care Management program, ensuring they receive comprehensive and continuous care. The Chronic Disease Management Nurse works collaboratively with healthcare providers, patients, and their families to create and implement personalized care plans, improve health outcomes, and reduce hospital readmissions.

Key Responsibilities:

Patient Coordination and Care Planning:
- Develop, implement, and monitor individualized care plans for patients with chronic conditions, in collaboration with healthcare providers and patients.
- Conduct regular check-ins with patients to assess their condition, adherence to treatment plans, and any changes in health status.
- Coordinate care across multiple providers and services to ensure comprehensive management of the patient's chronic conditions.
Patient Education and Support:
- Educate patients and their families on managing chronic conditions, including medication management, lifestyle changes, and preventive care.
- Provide emotional support and counseling to patients to encourage adherence to care plans and improve their quality of life.
- Act as a point of contact for patients and their families to answer questions, address concerns, and provide guidance on managing chronic conditions.
Care Coordination and Communication:
- Communicate regularly with physicians, nurses, and other healthcare providers to ensure cohesive care and address any issues or changes in the patient's condition.
- Coordinate referrals to specialists, community resources, and support services as needed.
- Maintain detailed and accurate patient records, documenting all interactions, care plans, and progress notes.
Quality Improvement and Reporting:
- Monitor and evaluate the effectiveness of care plans, making adjustments as necessary to meet patients' needs and goals.
- Track and report on key performance indicators related to chronic care management, such as patient outcomes, hospital readmission rates, and patient satisfaction.
- Participate in quality improvement initiatives to enhance the Chronic Care Management program and contribute to the overall improvement of healthcare delivery.

Qualifications:

Education:
- Associate or Bachelor’s Degree in Nursing, Social Work, or related healthcare field preferred.
Experience:
- Minimum of 2-3 years of experience in case management, chronic care management, or a related field in a healthcare setting.
Certifications:
- Registered Nurse (RN), Licensed Practical Nurse (LPN), or Medical Assistant (MA) certification required.
Skills and Competencies:
- Strong understanding of chronic disease management principles.
- Excellent communication and interpersonal skills.
- Proficiency in electronic health records (EHR) and care management software.
- Ability to work independently and as part of a multidisciplinary team.
- Strong organizational and problem-solving skills.

Physical Requirements:

Ability to sit for extended periods while managing patient records.
Occasional standing, walking, and lifting of materials up to 10 pounds.

Working Conditions:

Primarily works in an office setting with some opportunities for telehealth and remote/in-home patient interactions.
May require occasional travel to meet with patients or healthcare providers.

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